Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

An analysis of the relationship between injury severity and hospital inpatient costs Butt, Thomas Stephen 1982

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1982_A6_7 B89.pdf [ 6.1MB ]
Metadata
JSON: 831-1.0095314.json
JSON-LD: 831-1.0095314-ld.json
RDF/XML (Pretty): 831-1.0095314-rdf.xml
RDF/JSON: 831-1.0095314-rdf.json
Turtle: 831-1.0095314-turtle.txt
N-Triples: 831-1.0095314-rdf-ntriples.txt
Original Record: 831-1.0095314-source.json
Full Text
831-1.0095314-fulltext.txt
Citation
831-1.0095314.ris

Full Text

AN ANALYSIS OF THE RELATIONSHIP BETWEEN INJURY SEVERITY AND HOSPITAL INPATIENT COSTS  by THOMAS STEPHEN BUTT .A., B . S c , The U n i v e r s i t y of Waterloo,  1972, 1973  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in THE FACULTY OF GRADUATE STUDIES The Department o f H e a l t h Care and  We a c c e p t  this  t h e s i s as  Epidemiology  conforming  to the r e q u i r e d s t a n d a r d  THE UNIVERSITY OF BRITISH COLUMBIA August 1982 ( c T ) Thomas Stephen B u t t , 1982  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree at the  the  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  freely  a v a i l a b l e f o r reference  and  study.  I further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s f o r s c h o l a r l y purposes may  be  department or by h i s or her  granted by  the head o f  representatives.  understood t h a t copying or p u b l i c a t i o n o f t h i s for  financial  gain  The U n i v e r s i t y of B r i t i s h 1956 Main Mall Vancouver, Canada  V6T 1Y3  DE-6  <"}/8-n  Columbia  my  It is thesis  s h a l l not be allowed without my  permission.  thesis  written  ii  ABSTRACT  A sample of motor v e h i c l e a c c i d e n t  v i c t i m s h o s p i t a l i z e d at Vancouver  G e n e r a l H o s p i t a l , Vancouver, B r i t i s h Columbia, was the r e l a t i o n s h i p between h o s p i t a l c o s t s and i n j u r y or i l l n e s s .  S e v e r i t y was  the I n j u r y S e v e r i t y S c a l e and  was  the Per  c o s t s by  Diem c o s t s  measured u s i n g  two  average c o s t .  The  two  scales,  Injury Scale.  Hospital  days i n 1975.  A Per  determined by m u l t i p l y i n g l e n g t h of s t a y by  first  Diem the  daily  second approach used a step-down t e c h n i q u e t h a t  p a t i e n t c a r e departments, c o s t c e n t r e s developed f o r each c o s t c e n t r e ,  1975  The  t h a t were d e r i v e d by d i v i d i n g a l l r e l a t e d annual  t r i b u t e d a l l non-patient care r e l a t e d h o s p i t a l s e r v i c e s across  The  patient's  specifically,  d i f f e r e n t methodologies.  the number of p a t i e n t s e p a r a t i o n  e p i s o d i c c o s t was  analyze  the s e v e r i t y of the  the A b b r e v i a t e d  c o s t s were a l s o measured, u s i n g  chosen to  or programs.  Unit  direct  c o s t s were then  depending upon t h e i r annual w o r k l o a d .  m e d i c a l r e c o r d f o r each p a t i e n t i n the sample was  determine the number o f work u n i t s used i n each c o s t c e n t r e patient's h o s p i t a l stay.  dis-  A Step-Down e p i s o d i c c o s t was  t o t a l l i n g a l l c o s t s from each c o s t c e n t r e  that provided  analyzed during  to the  determined  by  s e r v i c e s to  the  patient.  A paired  t - T e s t d i d not  show a s i g n i f i c a n t d i f f e r e n c e between the  Diem and  Step-Down e p i s o d i c c o s t s .  I t was  assumed t h a t the range of  s e v e r i t y of the p a t i e n t i n the sample weakened t h i s s e v e r i t y measured by I.S.S. was  Per  grouped i n low,  t-Test,  medium, and  high  iii  categories, did  or when s e v e r i t y was measured by A.I.S., the p a i r e d  show t h a t  t h e r e was  a significant difference  i n the two  t-Test  costing  methodologies.  The r e g r e s s i o n both episodic  analysis costs  identified a significant relationship  and s e v e r i t y .  The s t r o n g e s t r e l a t i o n s h i p  between occurred  when s e v e r i t y was measured by I.S.S. and c o s t s were determined, u s i n g 2  the  Step-Down methodology  independent v a r i a b l e s  (R = 0 . 2 6 ,  (i.e.,  F = 35.45).  When o t h e r  related  d e a t h as outcome and o p e r a t i o n n o t p e r -  formed) and a l l i n t e r a c t i o n terms were i n t r o d u c e d , the r e g r e s s i o n c.o2 e f f i c i e n t i n c r e a s e d to R = 0 . 4 5 and the F v a l u e i n c r e a s e d to F = 2 4 . 9 .  Recommendations patients' of  were made to i n c l u d e  a severity  r e c o r d s to a s s i s t i n p a t i e n t  t h i s study was  r a t i n g on a l l h o s p i t a l i z e d  classification.  A final  outcome  i d e n t i f y i n g the v a l u e of a Step-Down approach to d e t e r -  mining h o s p i t a l costs  and i d e n t i f y i n g the l i m i t a t i o n s of the Per Diem  methodology o f h o s p i t a l  accounting.  iv  TABLE OF  CONTENTS Page  ABSTRACT LIST OF  i i TABLES  vi  L I S T OF EXHIBITS  v i i  ACKNOWLEDGEMENTS  viii  Chapter I.  INTRODUCTION  1  II.  REVIEW OF LITERATURE  8  Web o f C a u s a t i o n Economic E v a l u a t i o n E v a l u a t i o n Techniques H e a l t h Care V a l u a t i o n Components o f S e r v i c e s A f f e c t i n g H o s p i t a l C o s t s S e v e r i t y Measurement I I I . METHODOLOGY  34  P a t i e n t Data I d e n t i f i c a t i o n of D i r e c t P a t i e n t Costs A l l o c a t i o n o f Overhead Departments Drugs, M e d i c a l / S u r g i c a l S u p p l i e s , CSR Unit Values Nursing Units Emergency O p e r a t i n g Room Electroencephalography I n t e n s i v e Care U n i t Electrocardiography Laboratory Radiology Pharmacy P h y s i c a l Medicine ' IV.  8 11 13 19 23 29  DATA ANALYSIS  35 38 43 50 58 59 62 65 67 68 69 69 70 72 73 77  A.  Per Diem v e r s u s  Step-Down C o s t i n g  B.  A n a l y s i s of the I n f l u e n c e of S e v e r i t y on t h e V a r i a t i o n i n Cost Test f o r C u r v i l i n e a r i t y I n f l u e n c e o f Other Independent V a r i a b l e s R e g r e s s i o n Model  78 89 93 94 105  V  TABLE OF CONTENTS  (CONT'D)  Chapter  V.  SUMMARY AND CONCLUSIONS Sample P o p u l a t i o n - MVA V i c t i m s I n j u r y S e v e r i t y S c a l e - I.S.S. Other Independent V a r i a b l e s Step-Down C o s t i n g U t i l i t y o f R e l a t i o n s h i p Between E p i s o d i c Cost and S e v e r i t y  114 116 117 117 120  APPENDIX A  122  LITERATURE CITED  125  vi  LIST OF TABLES Table A.  Page MVA L o s s e s and S e p a r a t i o n s from B r i t i s h Hospitals  Columbia 1  B.  S o c i e t a l Losses •  15  C.  MVA  37  D.  Step-Down A l l o c a t i o n  40  E.  P a i r e d t - T e s t E p i s o d i c Costs  78  F.  Two  F a c t o r ANOVA-Episodic  Cost and A.I.S  81  G.  Two  F a c t o r ANOVA-Episodic  Cost and I.S.S  82  H.  P a i r e d t - T e s t D a i l y Cost  K.  Two  F a c t o r ANOVA-Daily  Cost and I.S.S  85  L.  Two  F a c t o r ANOVA-Daily  Cost and A.I.S  86  M.  R e g r e s s i o n E p i s o d i c C o s t s w i t h I.S.S  89  N.  R e g r e s s i o n E p i s o d i c C o s t s w i t h A.I.S  90  P.  R e g r e s s i o n of Component C o s t s w i t h S e v e r i t y  92  Q.  Test f o r C u r v i l i n e a r i t y  93  R.  R e g r e s s i o n of E p i s o d i c Cost w i t h M u l t i p l e  V i c t i m s by A.I.S. C l a s s i f i c a t i o n  Independent V a r i a b l e s and I.S.S.  .  .  S.  C o - e f f i c i e n t s of Independent V a r i a b l e s and I.S.S.  T.  R e g r e s s i o n of E p i s o d i c Cost w i t h M u l t i p l e  97 . .  Independent V a r i a b l e s and A.I.S U.  C o - e f f i c i e n t s o f Independent V a r i a b l e s and A.I.S.  V.  C o - e f f i c i e n t s o f Independent V a r i a b l e s i n the R e g r e s s i o n Models  84  98  101 . .  102  107  vii  L I S T OF EXHIBITS Exhibits  Page  P o t e n t i a l P a y o f f f o r P r e v e n t i v e Program f o r MVA  - F i g u r e 1 & IA  4  A l l o c a t i o n Formula "A" Square. Footage o f F l o o r A r e a  42  A l l o c a t i o n Formula "B" Building Depreciation Allocation Equipment D e p r e c i a t i o n  45  A l l o c a t i o n Formula "C" Employee B e n e f i t s and S a l a r i e s  46  .  A l l o c a t i o n Formula "D" E s t i m a t e d D i s t r i b u t i o n of Laundry and L i n e n by F u n c t i o n a l A r e a  Expense 49  A l l o c a t i o n Formula "E" Drug Expense From the Cost C e n t r e P r i n t o u t  51  A l l o c a t i o n Formula "F" S u r g i c a l and Other M e d i c a l S u p p l i e s  53  A l l o c a t i o n Formula "G" M e d i c a l Record Department  Services  . . .  54  A l l o c a t i o n Formula "H" Nursing Administration  56  Graph 1 S e v e r i t y by Age  96  Graph 2 - Model 1 Step-Down Cost by O p e r a t i o n , Death and I.S.S  108  Graph 3 - Model 1 P e r Diem C o s t by O p e r a t i o n , Death and I.S.S  109  Graph 4 - Model 2 Step-Down Cost by O p e r a t i o n , Death, S e v e r i t y and I n t e r a c t i o n Terms Graph 5 - Model 2 P e r Diem Cost by O p e r a t i o n , Death, S e v e r i t y I n t e r a c t i o n Terms  I l l  and 112  viii  ACKNOWLEDGEMENTS  T h i s t h e s i s would n o t have been p o s s i b l e t o complete w i t h o u t t h e u n l i m i t e d p a t i e n c e and support C h r i s Long d e s e r v e s supporting  this  o f a l l those  involved i n i t s production.  p a r t i c u l a r r e c o g n i t i o n f o r her endurance i n  endeavor.  Mary Y a t e s and Agnew Peckham and A s s o c i a t e s  were o f g r e a t h e l p i n t h e p r o d u c t i o n  o f t h e many d r a f t  copies of t h i s  report.  Many thanks a r e g i v e n t o Bob Evans, who had t o s u p e r v i s e t h i s t h e s i s over  s e v e r a l y e a r s and a c r o s s thousands o f m i l e s .  d i s t a n c e , v a l u a b l e a s s i s t a n c e was p r o v i d e d t i o n and a n a l y s i s of t h e r e s e a r c h t a s k s . T e r r y Delmore and J a c k W i l l i a m s and  Because of t h i s  locally  i n the interpreta-  For t h i s ,  I am g r a t e f u l t o  o f t h e H e a l t h Research U n i t ,  t o J i m H a r r o l d , P e t e r Hawrylyshyn, E v e l y n L a z a r e  Toronto,  and Frank  Markel.  Without t h e i r h e l p , t h e r e would n o t be a completed t h e s i s a t t h i s or any time i n t h e f u t u r e .  Finally,  the f i n a n c i a l support  acknowledged.  I t allowed  p r o v i d e d by I.C.B.C. i s g r a t e f u l l y  the author  time to c o l l e c t  the o r i g i n a l  d a t a and made p o s s i b l e i n - d e p t h computer a s s i s t e d d a t a a n a l y s i s .  time,  INTRODUCTION In the 1974 federal government working document, "A New Perspective on the Health of Canadians," accidental death (to which t r a f f i c death was the largest contributor) was identified as the number one k i l l e r for Canadians below the age of 40. Every year i n Canada approximately 6,000 people die i n road accidents and up to 35 times that number are involved i n injury-producing accidents.  1  A recent Nova Scotia study  2  pointed out  that 25% to 30% of a l l motor vehicle accident (MVA) victims are hospitalized and another 30% use hospital outpatient c l i n i c s .  The following  table displays separations and patient separation days ( i . e . , hospital bed days accumulated by those patients discharged i n each calendar year) for MVA victims hospitalized i n B r i t i s h Columbia for the years 1972 through 1977. MVA victims are identified by the ICD-9 E-codes 810-819, which c l a s s i f y patients by external cause of injury, i . e . , motor vehicle t r a f f i c accidents. TABLE A MVA Length of Stay and Separations From B r i t i s h Columbia Hospitals 1972 12,300  1973 14,500  1974 14,600  1975 13,300  Separations Patient Separation Days 124,500 146,200 150,300 134,800 Average Length 10.12 10.08 10.29 10.13 of Stay Days Days Days Days Source:  1976 12,800  1977 13,200  124,800 128,000 9.75 9.69 Days Days  Publication of B r i t i s h Columbia Ministry of Health, S t a t i s t i c s of Hospitalized Accidents (Annual Issue), Hospital Program Branch, Research Division.  ''l.alonde M., A New Perspective of the Health of Canadians: A Working Document, Ottawa, A p r i l 1974. 2 Chipman M.L., "Hospitalization after MVA i n Nova Scotia," Canadian Journal of Public Health, Vol.64, March 1973. - 1-  -  The h i g h deaths and two  2 -  i n j u r i e s r a t e s from MVA's a r e d i s t u r b i n g f o r  reasons: •  the p o t e n t i a l f o r p r e v e n t i v e programs - v a r i o u s s a f e t y and p r e v e n t i v e measures c o u l d reduce the number of a c c i dents  by c o u n t e r i n g the e t i o l o g i c a l  f a c t o r s of MVA's;  o the burden on the p u b l i c - the c o s t of v i c t i m s ' h o s p i t a l i z a t i o n i s imposed on the p u b l i c l y supported  h e a l t h care  system.  Those who  a l l o c a t e s o c i e t y ' s l i m i t e d r e s o u r c e s must  continually  evaluate a s p e c i f i c a l l o c a t i o n of resources r e l a t i v e t h a t c o u l d be done w i t h  the same r e s o u r c e s . T h e r e  to o t h e r  are two  to be c o n s i d e r e d i n t h e ' a l l o c a t i o n of p u b l i c r e s o u r c e s programs f o r motor v e h i c l e a c c i d e n t s . r e t u r n s on the investment through  necessary  The  first  issues  to p r e v e n t i v e  i s whether  to reduce trauma and  MVA's a r e b e t t e r than the r e t u r n s on investments  h e a l t h programs.  things  the  death i n other  What b e n e f i t s a r e l o s t or foregone when r e s o u r c e s  a r e a p p l i e d to motor v e h i c l e a c c i d e n t p r e v e n t i o n as opposed to o t h e r h e a l t h care programs such as cancer p r e v e n t i o n or r e d u c i n g i n c i d e n c e of b i r t h d e f e c t s ? MVA  The  the  second i s s u e r e q u i r e s c h o o s i n g  the  p r e v e n t i v e program which w i l l r e t u r n the g r e a t e s t b e n e f i t .  Programs to p r e v e n t motor v e h i c l e a c c i d e n t s can p o t e n t i a l l y l i v e s and reduce i n j u r y .  save  I n the l a t e 1960's, MVA's were i n c l u d e d  - 3 -  i n a d i s e a s e c o n t r o l program conducted by the Department o f H e a l t h , Education  and W e l f a r e  i n the United S t a t e s .  Despite  t h e seemingly  h i g h p o t e n t i a l p a y o f f o f some motor v e h i c l e a c c i d e n t programs (see F i g u r e 1 ) , t h e r e appears t o be c o n s i d e r a b l e u n c e r t a i n t y about  their  3 success.  Recommendations c a l l f o r implementation  o f s m a l l educa-  t i o n a l o r p r e v e n t i v e programs w i t h a l a r g e emphasis on e v a l u a t i o n o f g o a l attainment  f o r use i n f u t u r e d e c i s i o n s .  There a r e many approaches to d e f i n i n g the consequences o f p r e v e n t i v e programs, as w i l l be e x p l o r e d i n the next interest  to the author,  chapter.  Of p a r t i c u l a r  however, i s the r e l a t i o n s h i p between  r e d u c i n g s e v e r i t y and r e d u c i n g  the c o s t t o t h e p u b l i c o f h o s p i t a l i z i n g  v i c t i m s o f motor v e h i c l e a c c i d e n t s .  Thus, t h e main o b j e c t i v e o f t h i s  t h e s i s i s t o f i n d u n i t s o f measurement t h a t c a n a d e q u a t e l y s e v e r i t y and h o s p i t a l c o s t s .  I f a significant relationship  between s e v e r i t y and h o s p i t a l c o s t s , then c a l c u l a t i n g  define exists  t h e impact o f  a p r e v e n t i v e program o r i e n t e d t o o n l y one o f these consequences w i l l a l s o determine t h e impact on the o t h e r .  H o s p i t a l accounting for  systems i n Canada do n o t generate  component h e a l t h s e r v i c e s p r o v i d e d  accurate  costs  to i n d i v i d u a l p a t i e n t s .  T r a d i t i o n a l methods of c o s t d e t e r m i n a t i o n  i n a hospital setting are  based on p a t i e n t days as a measure o f output;  they a r e much too  Grosse R.N., " C o s t - B e n e f i t A n a l y s i s of H e a l t h S e r v i c e s , " American Academy of P o l i t i c a l and S o c i a l S c i e n c e s , P h i l . A n n a l s 399, 1972.  - 4P o t e n t i a l Payoff f o r Preventive Program f o r MVA Figure 1  •CANCKK  PROGRAMS COMPARED TO OTHER PKOCRAMS  600  500  400  100 Horizontal:  110  Averted—in thousand!, Vertical: Cost in millions of dollars * Includes programs on use of seat belts, defensive driving, and reduction in pedestrian injuries.  F i g u r e IA  Deaths  -DOLLAR SAVING IN CANCER PROGRAMS COMPARED TO OTHER TREATMENT  PROGRAMS-  600  500  Horizontal: Savings in billions of dollars Vertical: Program costs in millions of dollars  * Includes programs on use of seat belts, defensive driving, and reduction in pedestrian injuries.  Source:  G r o s s e R.N., "Cost B e n e f i t A n a l y s i s o f H e a l t h S e r v i c e s , " American Academy o f P o l i t i c a l and S o c i a l S c i e n c e s , P h i l . Annals 399,1972.  general  t o be  or t h e r a p e u t i c  of a n a l y t i c a l use services.  for s p e c i f i c diagnostic  Frequently,  programs of c a r e i n a  h o s p i t a l s e t t i n g do n o t n e c e s s a r i l y f o l l o w the hierarchy  of the o r g a n i z a t i o n ;  treatment  thus, the  departmental  l i n e i t e m budget, the  key  4 element i n c o n t r o l of n o t - f o r - p r o f i t o r g a n i z a t i o n s u s e f u l management c o n t r o l t o o l . not n e c e s s a r i l y to p a t i e n t these g r o u p i n g s .  Even w i t h the  t h e r e has  change to g l o b a l budgets e x p e r i e n c e d  l a s t decade, i d e n t i f i c a t i o n of  been no  p a t i e n t s , so too  so d i f f i c u l t  fails  due  the i n t e n s i t y of s e r v i c e s p r o v i d e d  who  have a s p e c i f i c d i s e a s e  within It  each d i s e a s e  costs.  to i d e n t i f y f o r i n d i v i d u a l Most c o s t  t h a t h o s p i t a l s t r e a t or to c o n t r o l  for  classification,  readily  to an i n a b i l i t y e i t h e r to account f o r  the d i f f e r e n t types of p a t i e n t s  of d i s e a s e  overhead  i s an a c c e p t a b l e code f o r s e v e r i t y .  analysis research  costs  attempt to i d e n t i f y output measures  of h o s p i t a l s e r v i c e s w i t h t h e i r o p e r a t i o n a l and  J u s t as h o s p i t a l c o s t s are  centres,  transcend  treatment, t h e r a p y or d i a g n o s t i c programs i s s t i l l n o t  a v a i l a b l e , as  a  C o s t s are a l l o c a t e d to c o s t  c a r e programs t h a t r e g u l a r l y  i n Canadian h o s p i t a l s i n the for  , i s not  may  be  the p a t i e n t .  coded u s i n g  i t is difficult  code w i t h r e s p e c t  While  patients  a t r a d i t i o n a l method  to m a i n t a i n  homogeneity  to h o s p i t a l e p i s o d i c  costs.  i s the assumption of t h i s a u t h o r t h a t s e v e r i t y coding would  provide e l a s t i c i t y  D e c o s t e r D.T. T o r o n t o , 1979,  to t r a d i t i o n a l p a t i e n t  and S c h a f e r E.L., pg.693.  c l a s s i f i c a t i o n methods;  Management A c c o u n t i n g , W i l e y and  Sons  - 6 -  t h i s could  improve c o s t a n a l y s i s r e s e a r c h .  greatest value,  Moreover,  severity's  p a r t i c u l a r l y i n the a n a l y s i s of motor v e h i c l e  accident  v i c t i m s , i s t h a t i t c o u l d p r o v i d e a s i n g l e code f o r  multiple  injury victims.  This  t h e s i s w i l l d e a l s o l e l y w i t h the methodology needed to d e t e r m i n e ,  to a r e a s o n a b l e degree of a c c u r a c y and of h o s p i t a l s e r v i c e s p r o v i d e d be  to MVA  feasibility,  victims.  Two  the d i r e c t c o s t s assessments w i l l  performed to d e t e r m i n e i f the chosen methodology r e s u l t s i n a  significant costing. w i l l be  d i f f e r e n c e from r e s u l t s of t r a d i t i o n a l Per  First,  episodic  c a l c u l a t e d by  compared to those c a l c u l a t e d by Per  secondly, p a t i e n t average of the Per  Data w i l l be costs  costs  and  severity.  specific  the proposed methodology  Diem average c o s t s ;  d a i l y c o s t s w i l l be  compared w i t h d a i l y  Diem methodology.  a n a l y z e d to determine the  i n j u r y s e v e r i t y , and The  Diem average  c o r r e l a t i o n between e p i s o d i c  between per  diem c o s t and  injury  o b j e c t i v e here i s to a s s e s s whether s e v e r i t y can  used as a treatment p r o f i l e f o r the d e t e r m i n a t i o n of h o s p i t a l Such a c o r r e l a t i o n c o u l d  a s s i s t the d e c i s i o n - m a k i n g p r o c e s s  the  i m p l e m e n t a t i o n of i n j u r y - r e d u c i n g  the  impact) p r e v e n t i v e  the  cost  measures.  ( i . e . , reducing  be  costs.  regarding  s e v e r i t y of  With a s i g n i f i c a n t c o r r e l a t i o n ,  to the h o s p i t a l system c o u l d be  projected  l e v e l of i n j u r i e s expected a f t e r i m p l e m e n t a t i o n of  i f the  severity  preventive  - 7 -  programs c o u l d be  estimated.  F i n a l l y , d a t a a n a l y s i s w i l l determine major c o n t r i b u t o r s to e p i s o d i c c o s t ; i s l e n g t h o f s t a y the s i g n i f i c a n t  i n d i c a t o r , or are other  v a r i a b l e s i n the h o s p i t a l treatment p r o c e s s more s i g n i f i c a n t determination  of t h i s  cost?  to t h e  - 8 -  II.  The  REVIEW OF LITERATURE  Oxford  D i c t i o n a r y d e f i n e s " a c c i d e n t " as f o l l o w s :  happening by chance, w i t h o u t  p l a n o r cause; a mishap u s u a l l y  r e s u l t i n g i n harm, i n j u r y , o r damage." accurate,  "an event  I f this definition i s  and t h e r e i s no cause o r c a u s a l agent f o r an a c c i d e n t ,  how c a n counter measures be implemented t o l i m i t accidents, especially  traffic  t h e e f f e c t s of  accidents?  Web of C a u s a t i o n Most a c c i d e n t s o f our s o c i e t y ( t r a f f i c , home, r e c r e a t i o n , and i n d u s t r i a l ) are u s u a l l y personal occurrences i n degree o f s e v e r i t y of outcome. a c c i d e n t s do n o t g e t r e p o r t e d thus d i f f i c u l t  v a r y i n g i n l o c a t i o n and  As a r e s u l t , many of these  and so do n o t g e t c a t e g o r i z e d ; i t i s  t o d e t e r m i n e a c a u s a l agent and then to d e v e l o p  a p p r o p r i a t e remedies.  What s e p a r a t e s  traffic  from o t h e r  types o f  a c c i d e n t s i s t h a t t h e i r environment i s g e n e r a l l y n e i t h e r s t a b l e nor repetitive.  T r a f f i c a c c i d e n t s a r e an e c l e c t i c combination of non-  s p e c i f i c events t h a t come t o g e t h e r  The  momentarily.  term " a c c i d e n t , " i n most c a s e s ,  sense.  i s a misnomer i n an e t i o l o g i c  Haddon spoke q u i t e s t r o n g l y on t h i s concept when he d i s c u s s e d  the t r a n s i t i o n t o e t i o l o g i c study  of trauma.^  He was c r i t i c a l o f  Haddon W., "The T r a n s i t i o n t o Approaches E t i o l o g i c a l l y r a t h e r than D e s c r i p t i v e l y Based, w i t h r e s p e c t t o E p i d e m i o l o g y P r e v e n t i o n and A m e l i o r a t i o n o f Trauma," American J o u r n a l of P u b l i c H e a l t h , V o l . 5 8 August 1968.  - 9 -  p r o f e s s i o n a l s who  brought to t h e i r r e s e a r c h  to such c o n c e p t s as introduced  luck,  chance, and  into their s c i e n t i f i c  personal  mishap; by  predispositions  d o i n g so,  they  framework n o n - s c i e n t i f i c elements.  2 I n a 1975 regard  report  , Haddon f u r t h e r d e s c r i b e d  to the motor v e h i c l e a c c i d e n t  by  t h i s r e l a t i o n s h i p with  adding to the  m e c h a n i c a l energy t r a n s f e r which o c c u r s d u r i n g o t h e r concepts such as  thermal, e l e c t r i c a l ,  r a d i a t i o n energy t r a n s f e r s . c o u l d be made on  growth of r e s e a r c h  on b o t h the  forces  a traffic  c h e m i c a l , and  I n a d d i t i o n , he  the human element and  normal accident, ionization  suggested s t u d i e s  made f u r t h e r r e f e r e n c e  that to  the  t h a t produce i n j u r i e s to 3  animate and  i n a n i m a t e s t r u c t u r e s , and  F i n a l l y , Haddon s t r e s s e d t h a t reduce the  ....  r  the ways these can be  the importance of c h o o s i n g c o u n t e r measures  damage, not n e c e s s a r i l y ones t h a t p r e v e n t  u  •  i n i t i a t i o n of the  impact.  blaming the v i c t i m and  and  the  4  Another a r e a of study suggested by Haddon was  the b e h a v i o u r a l  avoided.  ignoring  the  s o c i e t y ' s penchant f o r  c a u s a l sequence."'  a s p e c t s of the motor v e h i c l e a c c i d e n t  T h i s a r e a of i s highly  inbred  i s concerned almost e x c l u s i v e l y w i t h the d e s c r i p t i v e , not e t i o l o g i c  2 Haddon W., "Reducing Damage of Motor V e h i c l e Use," July/August, 1975.  Technology Review,  3  Haddon W., Suchman E.A., and K l e i n P., and Approaches, New York, Harper & Row, ^Ibid.,3. 5  Ibid.,3.  Accident 1964.  R e s e a r c h - Methods  - 10  n o t i o n of the t r a f f i c a c c i d e n t .  -  T h i s can be no b e t t e r  illustrated  than t h e r e p o r t to the Congress from the S e c r e t a r y of T r a n s p o r t a t i o n , " A l c o h o l and Highway S a f e t y " , w i t h i n which most of the deals with  the e f f e c t a l c o h o l has  information  on the p e r s o n , w i t h l i t t l e  r e c o g n i t i o n of the c a u s a l sequence of the events l e a d i n g to accident.  recognized  a l c o h o l and  to a l s o s t o p  the d e a r t h  the  driving,  and  the drunk from d r i v i n g .  The  author  of i n f o r m a t i o n on the r a m i f i c a t i o n s of formulated  exhaustively explored before related  no  F o r example, the problem i s n o t o n l y to s t o p the d r i v e r  from d r i n k i n g , b u t has  or  t r a f f i c accidents  many q u e s t i o n s  e f f e c t i v e counter  can be  A t a r e c e n t World Congress on  t h a t have to  be  measures f o r a l c o h o l  determined.  the p r o v i s i o n of m e d i c a l  s e r v i c e s to  t r a f f i c a c c i d e n t v i c t i m s , f i v e s t e p s were o u t l i n e d f o r the management of the motor v e h i c l e a c c i d e n t : • investigation; • a n a l y s i s and i n t e r p r e t a t i o n ; • planning  c o n t r o l programs;  • i m p l e m e n t a t i o n of counter  measures;  and  • evaluation.^  Schwenger C , A l c o h o l and Highway S a f e t y , A the S e c r e t a r y of T r a n s p o r t a t i o n , 1967. W.H.O., " A c c i d e n t s  7  Report to Congress from  i n a S o c i a l C o n t e x t , " C h r o n i c l e 27,  1973.  - 11 -  These f i v e s t e p s support Haddon's e t i o l o g i c a l approach t o accidents, especially  the p l a n n i n g s t a g e where r e s e a r c h e r s can work  w i t h what i s known, and happened. be any  traffic  determine a l t e r n a t i v e s  to t h a t which  has  T h i s l e a d s to the assumption t h a t t r a f f i c a c c i d e n t s  a n a l y z e d by  the s t a n d a r d e p i d e m i o l o g i c a l methods used to  other disease:  can  analyze  a s u s c e p t i b l e h o s t , a p r e d i s p o s i n g environment,  an i n c i t i n g agent, and  their interaction.  i n f o r m a t i o n on who  them, where they took p l a c e , and when and  had  they o c c u r r e d ; on d i f f e r e n t  A c c i d e n t data must i n c l u d e  c l a s s e s of i n j u r i e s f o r c a u s a l  how  agents;  g  and  on the mechanism of  injury.  Economic E v a l u a t i o n I n t h i s e r a of l i m i t e d c o n s i s t e n t and  comparable d a t a , a p p r o p r i a t e defence  j u s t i f i c a t i o n of new the f i v e items  r e s o u r c e s , h e a l t h care p l a n n e r s must  listed  and  ongoing programs.  earlier,  According  program  i n t o two  those c h a r a c t e r i s t i c s  d i s t i n g u i s h one program from another, quality audit (sic),  areas,  that  eg. c o s t ,  a p p r o p r i a t e n e s s of management  to s u p p l y s e r v i c e s  Murray J.E., " E t i o l o g y of MVA w i t h S p e c i a l Reference of I n j u r y , " N.E. J o u r n a l of M e d i c i n e NE 492, June 20, Q  ranking  attainment:  0 program q u a l i t i e s —  decision, a b i l i t y  to M a r t i n , of  to manage motor v e h i c l e  M a r t i n d i v i d e d t h i s e v a l u a t i o n process  program q u a l i t i e s and  adequate  program e v a l u a t i o n i s the 9  i s s u e f o r m a i n t a i n i n g an e f f e c t i v e program accidents.  and  supply  to the Mechanism 1968.  M a r t i n D.L., H e a l t h Program E v a l u a t i o n , A Primer Report to the F e d e r a l P r o v i n c i a l Sub-Committee on Q u a l i t y o f Care and R e s e a r c h and F e d e r a l P r o v i n c i a l A d v i s o r y Committee on H e a l t h I n s u r a n c e , 1977 V o l . 1 .  - 12 -  • program a t t a i n m e n t —  measures e f f i c a c y ,  efficiency,  e f f e c t i v e n e s s and s i d e e f f e c t s (unwelcome outcomes of implementing Martin and  further defined  program q u a l i t y .  the program).  10  the r e l a t i o n s h i p between program a t t a i n m e n t Nevertheless,  o n l y " c o s t " appears l a t e r i n  h i s p r i m e r as a j u s t i f i c a t i o n f o r d e v e l o p i n g  more f o r m a l  i n e v a l u a t i o n o f programs, e s p e c i a l l y when " s t a k e s d e c i s i o n may be h i g h ,  techniques  involved  i n the  i n c o r p o r a t i n g not o n l y programs p r e s e n t l y i n  o p e r a t i o n b u t a l s o proposed o r completed programs when they become p r e c e d e n t s f o r f u t u r e decision."^"'"  Martin  and h i s working  party  took t h e view t h a t a genuine demand e x i s t s by a d m i n i s t r a t o r s t h e i r p o l i t i c a l masters f o r g r e a t e r  a c c o u n t a b i l i t y , cost  and  effectiveness  12 and  c o s t c o n t r o l i n h e a l t h care  , i . e . f o r program  qualities.  D e v e l o p i n g a comparative r e l a t i o n s h i p between program a t t a i n m e n t s and  program q u a l i t i e s f o r p r e v e n t i v e  an economic Preventive  evaluation. programs a r e a c t i o n s made w i t h t h e e x p e c t a t i o n o f  s a t i s f a c t o r i l y achieving Therefore  h e a l t h programs i s the b a s i s o f  o b j e c t i v e s which maximize b e n e f i t s over  evaluation of preventive  f u t u r e to i d e n t i f y  programs must be o r i e n t e d  costs.  t o the  the p o t e n t i a l b e n e f i t s from i n v e s t i n g t h e c o s t s  of implementing p r e v e n t i v e  programs.  Stoddart  defines  this  type o f  M a r t i n D.L., H e a l t h Program E v a l u a t i o n , A P r i m e r Report to t h e F e d e r a l P r o v i n c i a l A d v i s o r y Committee on H e a l t h I n s u r a n c e , 1977 V o l . I I .  op.cit.,9.  - 13  -  e v a l u a t i o n as economic e v a l u a t i o n —  the comparative a n a l y s i s of  a l t e r n a t i v e c o u r s e s of a c t i o n i n terms of b o t h t h e i r c o s t s  and  13 consequences.  He  further identifies  e v a l u a t i o n as i t s a b i l i t y The  by  committing  the r e s o u r c e s  two  program i s not  the number of d o l l a r s  i n the budget; i t i s the h e a l t h outcomes o r  achievable  The  of economic  to c l e a r l y i d e n t i f y r e l e v a n t a l t e r n a t i v e s .  r e a l c o s t of a p r e v e n t i v e  appearing  the v a l u e  consequences  some o t h e r program w h i c h have been f o r e g o n e by i n question  to the f i r s t  program.  components under s t u d y i n t h i s t h e s i s , i . e . , s e v e r i t y  and  h o s p i t a l c o s t s , a r e b o t h consequences or measures of outcomes of preventive  programs.  S e v e r i t y can be  measuring q u a l i t y of l i f e ,  while  e x i s t i n g c o s t s which c o u l d be programs prove e f f e c t i v e .  grouped w i t h  those consequences  h o s p i t a l treatment costs  reduced or e l i m i n a t e d  are  i f preventive  I n a m a j o r i t y of economic e v a l u a t i o n s ,  these p r e s e n t  and  p o t e n t i a l l y avoidable  c o s t s have t o be  from r e s o u r c e  c o s t s r e q u i r e d to o p e r a t e the p r e v e n t i v e  distinguished  program!"'  E v a l u a t i o n Techniques A f o r m a l and  systematic  approach to a l l o c a t i n g p u b l i c d o l l a r s ,  as economic e v a l u a t i o n , has  o n l y been used f o r a g e n e r a t i o n  or  such so.  S t o d d a r t G.L., On D e t e r m i n i n g the E f f i c i e n c y of H e a l t h Programs> U n p u b l i s h e d a r t i c l e , Department of C l i n i c a l Epidemology and B i o s t a t i s t i c s and Department o f Economics, McMaster U n i v e r s i t y . l ^ S t o d d a r t G.L.,  Ibid.,  13.  Klarman H.E., " A p p l i c a t i o n s of Cost B e n e f i t A n a l y s i s to the H e a l t h S e r v i c e s and the S p e c i a l Case of T e c h n o l o g i c I n n o v a t i o n , " I n t e r n a t i o n a l J o u r n a l of H e a l t h S e r v i c e s , V o l . 4 , No.2, Nov. 2, 1974.  - 14  As Klarman p o i n t s out,  -  the e a r l i e s t reviews u s i n g  were i n the l a t e 1950's and  concentrated  these  techniques  on water r e s o u r c e s  projects.  H i s r e v i e w of c o s t b e n e f i t l i t e r a t u r e i d e n t i f i e s most major of economic e v a l u a t i o n i n h e a l t h c a r e up  The method of measuring c o s t s and of e v a l u a t i o n .  I n most cases,  s i m i l a r , r e g a r d l e s s of the F o r MVA,  preventive  reports  to the mid-1970's.  consequences v a r i e s w i t h  the  the measurement of r e s o u r c e  costs i s  t e c h n i q u e chosen f o r the economic  programs r e s o u r c e  evaluation.  c o s t s can be r e a d i l y i d e n t i f i e d .  Car m a n u f a c t u r e r s know the c o s t of e q u i p p i n g  vehicles with  seat b e l t s  o r a i r bags; s i m i l a r l y , budgets f o r a d v e r t i s i n g campaigns and l e g i s l a t i o n can be  easily  policing  determined.  The measurement of consequences, though, v a r i e s depending on q u e s t i o n posed i n the e v a l u a t i o n and whether o r not been p r o v e n e f f e c t i v e . ^  subject  the program  Cost b e n e f i t a n a l y s i s i s the most  t e c h n i q u e of economic e v a l u a t i o n .  D o l l a r s are  the has  extensive  the measure commonly 18  used to f a c i l i t a t e  comparison of b e n e f i t s a c r o s s v a r i o u s  Thus a l l b e n e f i t s must have a d o l l a r v a l u e ; s e r v i c e s avoided,  d i s a b i l i t y days a v o i d e d  programs.  these i n c l u d e h e a l t h  and  l i f e years  gained.  Table  B l i s t s Fargan's i n t e r p r e t a t i o n o f b e n e f i t s o r c o s t s t o be 19 a v o i d e d through a r e d u c t i o n i n MVA. D i r e c t b e n e f i t s are those  Klarman H.E., "^Stoddart  G.L.,  Ibid.,15. op.cit.,  13.  18 Musgrave R.A., "Cost B e n e f i t A n a l y s i s and the Theory of P u b l i c J o u r n a l of Economic L i t e r a t u r e , V o l . 7 , No.3, 1969.  Finance,"  F a r g a n B.M., "1975 S o c i e t a l Costs of Motor V e h i c l e A c c i d e n t s , " U.S. Department of T r a n s p o r t a t i o n , N a t i o n a l Highway T r a f f i c S a f e t y Administ r a t i o n , December 1976, page 30.  TABLE B S o c i e t a l Losses  Direct  (sic)*  P r o d u c t i o n / C o n s u m p t i o n market Home, F a m i l y  Indirect  and Community  costs  costs  (sic)*  Medical  costs  - hospital - physician - coroner -  rehabilitation  V e h i c l e damage L o s s e s to o t h e r s L e g a l and Court Funeral Insurance Accident Traffic Source:  administration investigation  delay F a r g a n B.M., "1975 S o c i e t a l C o s t s of Motor V e h i c l e A c c i d e n t s , " U.S. Department of T r a n s p o r t a t i o n , N a t i o n a l Highway T r a f f i c S a f e t y A d m i n i s t r a t i o n , December 1976, page 30.  *The u s u a l usage o f i n d i r e c t and d i r e c t c o s t s f o r s o c i e t a l r e v e r s e to the d e f i n i t i o n s p r e s e n t e d by F a r g a n .  l o s s e s are  - 16 -  related  to t h e i n d i v i d u a l t h a t can be e v a l u a t e d ,  i n d i r e c t b e n e f i t s a r e those a v e r t e d e.g., as  health  care.  c o s t s f o r s e r v i c e s o r equipment,  category,called  intangible benefits  the p o t e n t i a l of the i n d i v i d u a l to provide  coaching l i t t l e in  A third  e.g., p r o d u c t i v i t y ;  a volunteer  l e a g u e ) does n o t have a market v a l u e  (such  s e r v i c e , or  and i s n o t i n c l u d e d  the c o s t a n a l y s i s .  Cost-effectiveness  a n a l y s i s i s another common.form o f economic  evaluation.  T h i s i s an a n a l y s i s of t h e e f f e c t i v e n e s s o f s e v e r a l programs o f f e r i n g comparable outcomes. a single effect,  I n these a n a l y s e s ,  common t o a l l programs under review, which may  d i f f e r i n magnitude among these v a r i o u s is  t h e consequence i s u s u a l l y  programs.  The common e f f e c t  u s u a l l y measured i n n a t u r a l u n i t s , e.g., l i f e y e a r s g a i n e d or  disability  days s a v e d .  The consequence i n t h i s  type o f economic  e v a l u a t i o n i s n o t measured i n d o l l a r s .  Key '.components  of c o s t - e f f e c t i v e n e s s studies a r e the a b i l i t y  a m a r g i n a l c o s t o f , e.g., s a v i n g and  a d d i t i o n a l l i f e years  t o i d e n t i f y the b e s t mix o f programs t o p r o v i d e  years gained.  Since  this  type o f a n a l y s i s c o n c e n t r a t e s  I t i s , however, most a p p r o p r i a t e  programs where t h e o b j e c t i v e i s t o p r o l o n g  gained,  t h e maximum  consequence, i t l o s e s degrees o f s e n s i t i v i t y compared analysis.  to give  life  on o n l y one to cost b e n e f i t  i n evaluating health  care  life.  D i t t m a n D.A., and Smith K.R., " C o n s i d e r a t i o n of B e n e f i t s and C o s t s : A C o n c e p t u a l Framework f o r t h e H e a l t h P l a n n e r , " H e a l t h Care Management Review, F a l l 1979.  - 17 -  A c o r o l l a r y to c o s t - e f f e c t i v e n e s s a n a l y s i s i s c o s t - u t i l i t y a n a l y s i s ; h e r e , the consequence i s measured i n q u a l i t y - a d j u s t e d the c o s t s a r e a d j u s t e d the p r e v e n t i v e  program.  l i f e y e a r s and  t o account f o r a l l economic i m p l i c a t i o n s of T h i s methodology of economic e v a l u a t i o n i s  of d i r e c t i m p o r t a n c e t o t h i s t h e s i s as b o t h v a r i a b l e s b e i n g i.e.,  s e v e r i t y and h o s p i t a l c o s t s , can be i n c l u d e d  measured,  in a cost-utility  analysis.^  On the c o s t s i d e of t h e e q u a t i o n ,  program o p e r a t i n g  costs are modified  by: •  adding a l l h e a l t h c a r e c o s t s a s s o c i a t e d w i t h the s i d e e f f e c t s of i m p l e m e n t a t i o n of an MVA productive  0  program, e.g., l o s s o f  y e a r s due to drowning when s e a t b e l t i n h i b i t e d escape;  s u b t r a c t i n g a l l savings i n medical,  preventive  a s s o c i a t e d w i t h the programs, e.g.,  h o s p i t a l , r e h a b i l i t a t i o n and c u s t o d i a l c o s t s  savings  incurred  by the v i c t i m ; and 0  finally,  adding a l l c o s t s a s s o c i a t e d w i t h t r e a t i n g o t h e r  f o r v i c t i m s who  survived  as a r e s u l t of the p r e v e n t i v e  b u t who would not have s u r v i v e d  I t i s evident  under t h e o r i g i n a l  diseases  program,  conditions.  t h a t i d e n t i f i c a t i o n of h o s p i t a l c o s t s i s a v i t a l  component o f t h i s c o s t - u t i l i t y  analysis.  \ f e i n s t e i n M.C., and Stason W.B., " F o u n d a t i o n s of C o s t - E f f e c t i v e n e s s A n a l y s i s f o r H e a l t h and M e d i c a l P r a c t i c e s , " The New England J o u r n a l of M e d i c i n e , March 31, 1977.  - 18 -  On  the o t h e r s i d e o f the e q u a t i o n , u t i l i t y  i s the n e t h e a l t h -  e f f e c t i v e n e s s measured i n q u a l i t y - a d j u s t e d l i f e y e a r s saved. approach  This  f a c i l i t a t e s measurement o f the c o n d i t i o n s under which the  l i f e - y e a r saved i s l i v e d ,  e.g.,  a l i f e - y e a r saved i s l e s s  rewarding  spent i n a c h r o n i c h o s p i t a l t h a n spent i n the normal environment the v i c t i m p r i o r  t o the a c c i d e n t .  The expected number o f  of  unadjusted  l i f e y e a r s i s m o d i f i e d by a f a c t o r t h a t takes i n t o account  age,  pain  22 and  suffering,  i m m o b i l i t y and  l o s t earning  a l l o w s f o r t h e v i c t i m ' s s u b j e c t i v e comparison which saved l i f e y e a r s are spent and d e a t h .  of the v i c t i m .  It also  between c o n d i t i o n s under A l t h o u g h methods of  economic e v a l u a t i o n t h a t i n c l u d e q u a l i t y - a d j u s t e d l i f e y e a r s are 23 r e l a t i v e l y new, interpreting  t h e r e i s l i t t l e doubt of t h e i r v a l u e i n r e a l i s t i c a l l y  the e f f e c t i v e n e s s of h e a l t h c a r e programs.  A s s i g n i n g a n u m e r i c a l v a l u e to h e a l t h s t a t u s has become i n c r e a s i n g l y important  i n the l a s t s e v e r a l y e a r s .  s t u d y on the A l l o c a t i o n of Resources h e a l t h s t a t u s i n d i c a t o r s as a way  W e i n s t e i n and Stason, i n a to Manage H y p e r t e n s i o n , i n c l u d e d  t o develop q u a l i t y - a d j u s t e d  life  24 years.  K r i s c h e r reviewed  s e v e r a l s e v e r i t y s c a l e s on the  t h a t they were a s u b s e t o f h e a l t h s t a t u s i n d i c e s and  W e i n s t e i n M.C.,  and  S t a s o n W.B.,  that  assumption their  ibid.,21.  23 T o r r a n c e G.W., Thomas W.H., and S a c k e t t D.L., "A U t i l i t y M a x i m i z a t i o n Model f o r E v a l u a t i o n of H e a l t h Care Programs," H e a l t h S e r v i c e s R e s e a r c h , Summer \L972. W e i n s t e i n M.C., and S t a s o n W.B., " A l l o c a t i o n of Resources to Manage H y p e r t e n s i o n , " The New England J o u r n a l of M e d i c i n e , March 31, 1977.  -  properties health  had  status  originates  19  -  value for a l l health i n d i c e s , and  status  indices.  The  interest in  especially i n severity scales  i n the need to study the  e t i o l o g y of  for  the MVA  e v a l u a t e a l t e r n a t i v e programs, emergency c a r e and  and  MVA, to  l o n g term  health  25 c a r e needs. not  As  yet,  a s e v e r i t y v a l u e of an  been used to a d j u s t  life  q u a l i t y , but  i n j u r e d MVA  there i s merit  d e v e l o p i n g a r e l a t i o n s h i p between t h e s e v e r i t y of measure of l i f e program.  q u a l i t y , and  S t a t e d a n o t h e r way,  programs reduce s e v e r i t y improve q u a l i t y of the  s i g n i f i c a n c e of  h o s p i t a l costs. could  the  Placing  the  the  d o l l a r s invested  i n preventive  victims  s i g n i f i c a n t l y and  This  thesis w i l l  t r y to i d e n t i f y and  r e s e a r c h on life  severity years.  Valuation the  costs  and  benefits costs  can be are  as  difficult  included  component s e r v i c e or i t e m i n each b e n e f i t / c o s t  i n the market p l a c e and  i n the  Intangible  and  s o c i e t a l losses  benefits  a r e not  as analysis.  area i s traded  b e a r s a p r i c e , t h a t p r i c e can be  only p r o d u c t i v i t y  market p l a c e .  thus  r e l a t i o n s h i p between i n j u r y s e v e r i t y  I f there i s s i g n i f i c a n c e , f u r t h e r  a v a l u e on  T a b l e B,  a  preventive  i d e n t i f y i n g which consequences and If  i n j u r y as  determine i t s v a l u e i n i d e n t i f y i n g q u a l i t y - a d j u s t e d  H e a l t h Care  to  to implement the  l i f e y e a r s saved? the  has  cost  can  of MVA  the  victim  used.  traded i n  of r e d u c i n g s o c i e t a l l o s s e s  K r i s c h e r J.P., "Indexes of S e v e r i t y : H e a l t h S e r v i c e s Research, Summer 1976.  From  Underlying Concepts,"  the  can  - 20 -  be  e l i m i n a t e d from the c o s t a n a l y s i s , as mentioned e a r l i e r ,  p r o d u c t i v i t y measured as a v a l u e o f a human l i f e  but  or i n d i s a b i l i t y  days must be c o n s i d e r e d i n a c o s t b e n e f i t study.  Most r e s e a r c h has been conducted p r o d u c t i v i t y and  as such  to date on p l a c i n g a v a l u e  t h i s a r e a w i l l not be reviewed  on  i n this  thesis.  Depending on the assumptions made by r e s e a r c h e r s , a d o l l a r v a l u e be determined life  If  f o r a l l a s p e c t s of p r o d u c t i v i t y , e.g.,  or d i s a b i l i t y  allows  v a l u e of human  days.  t h e r e i s q u e s t i o n as to the a c c u r a c y  p r i c e o f any  can  o r v a l i d i t y of the market  component i n the c o s t a n a l y s i s , a r e s o u r c e e x i s t s which  the development of a shadow p r i c e t h a t e s t i m a t e s an  imputed  26 cost.  This process  i s s l i g h t l y d i f f e r e n t from e s t i m a t i n g p r i c e  f o r p r o d u c t i v i t y as p r o d u c t i v i t y i s not t r a d e d i n the market p l a c e and  thus does not have an o r i g i n a l p r i c e .  identified  i n T a b l e B,  Of  the many c o s t s  the v a l i d i t y of the h e a l t h c a r e c o s t must  r e c e i v e the c l o s e s t s c r u t i n y .  L e g a l f e e s , f u n e r a l c o s t s and  damage a r e a l l t r a d e d r e g u l a r l y i n the market p l a c e and has a p r i c e  t h a t more o r l e s s r e f l e c t s  property  each s e r v i c e  the r e s o u r c e s used.  The  use  of h e a l t h r e s o u r c e s , e s p e c i a l l y t h o s e s e r v i c e s p r o v i d e d i n a h o s p i t a l , i s not p r i c e d to a c c u r a t e l y r e f l e c t c o s t s .  KlarmanH.E., o p . c i t . , 1 5 .  Mushkin.and C o l l i n g s , i n  - 21  the  -  l a t e 1950's, emphasized t h i s p o i n t when they o u t l i n e d  several  27 ways to e s t i m a t e e x p e n d i t u r e s by d i s e a s e  category.  W h i l e one  of  t h e i r solutions, using operating  c o s t s of s p e c i a l t y f a c i l i t i e s ( i . e .  eye  has  h o s p i t a l or T.B.  using  sanitarium)  average c o s t per  does not  accurately  patients.  case or per  identify  Further,  merit,  t h e i r s u g g e s t i o n s of  d u r a t i o n of h o s p i t a l s t a y  the c o s t of s e r v i c e s used by i n d i v i d u a l  overhead, t r a i n i n g of h e a l t h p e r s o n n e l  c o n s t r u c t i o n c o s t s were to be a l l o c a t e d on an i n d e x of importance, but given i n this  R i c e was  one  no  suggestions f o r developing  Her  and  relative  such an i n d e x were  article.  of  the r e s e a r c h e r s  methodology of e s t i m a t i n g costs.  still  research  at that  time to develop a u s e f u l  c o s t of i l l n e s s , b o t h d i r e c t and  included health  care costs  of  indirect  illnesses 28  categorized  using  the major d i a g n o s t i c groups of the ICDA code.  While her approach i d e n t i f i e d d i f f e r e n t average per different illnesses,  diem r a t e s  for  over a g i v e n y e a r ( f o r a l l p a t i e n t s f o r h e a l t h  s e r v i c e s under s p e c i f i e d p u b l i c programs o r those r e c e i v i n g c a r e the p r i v a t e s e c t o r ) , i t was  too g e n e r a l  to be  h o s p i t a l s e t t i n g or to account f o r m u l t i p l e  in  a p p l i e d to a s i n g l e  injuries.  Mushkin S.J. and C o l l i n g s F.d'A./'Economic C o s t s of D i s e a s e I n j u r y , " P u b l i c H e a l t h R e p o r t s , Vol.74,No.9, Sept. 1959.  and  28 R i c e D.P., " E s t i m a t i n g The C o s t of I l l n e s s , " American J o u r n a l P u b l i c H e a l t h , Vol.57,No.3, March 1967.  of  - 22  Determining  -  the a c t u a l c o s t of h e a l t h  arduous t a s k .  s e r v i c e s a t a h o s p i t a l i s an  Cost a c c o u n t i n g t e c h n i q u e s which have proven  successful  i n t r a d i t i o n a l b u s i n e s s s e t t i n g s have not been used i n n o t - f o r - p r o f i t h o s p i t a l s i n Canada. can not  A c c o r d i n g to H o l d e r , many h o s p i t a l managements  produce a budget t h a t . c a n  a c t u a l experience accurately  compare p r o j e c t e d  estimates  enough to p r o v i d e c o n t r o l over  and  costs  29 and  revenue.  o r any  But  the problems a s s o c i a t e d w i t h u s i n g  patient  v a r i a t i o n on p a t i e n t days f o r c o s t i n g of h o s p i t a l output  w e l l known.  Most r e s e a r c h e r s  agree t h a t h o s p i t a l c o s t s  should  an aggregate of u n i t c o s t s of i n d i v i d u a l s e r v i c e s consumed by patients.  Moreover, b r e a k i n g down s e r v i c e s , and  often gives  thus c o s t s  a c l e a r e r p i c t u r e of the v a r i a t i o n s i n c o s t  s e r v i c e than do  t o t a l program f i g u r e s .  departments/cost centres costed,  days  as was  Fortunately,  be the  into units,  to p e r f o r m a  most programs/  have e s t a b l i s h e d work u n i t s t h a t can  o u t l i n e d i n Macdonald and  are  Reuter's r e p o r t  be  on o b s t e t r i c  30 programs. new  C u r r e n t b u d g e t i n g p r a c t i c e s , even those t h a t  approaches l i k e Zero Based B u d g e t i n g , do not p r o v i d e  on work u n i t c o s t s . needed to i s o l a t e the  incorporate information  Thus a s e p a r a t e review of each h o s p i t a l i s c o s t s of d e p a r t m e n t a l work u n i t s .  The  American  H o l d e r W.W., " H o s p i t a l Budgeting: S t a t e of the A r t " , H o s p i t a l s H e a l t h S e r v i c e s A d m i n i s t r a t i o n , Vol.23 No.2, Spring 1978  and  30 Macdonald L.K.,. and^Reuter F., "A P a t i e n t S p e c i f i c Approach to C o s t A c c o u n t i n g , " H e a l t h S e r v i c e s R e s e a r c h, Summer 1973.  Hospital  - 23  Hospital Association, for  the  i n the  -  l a t e 1950's, developed a b a s i c  c o s t d e t e r m i n a t i o n of work u n i t s of a h o s p i t a l .  a p r o c e s s to d e t e r m i n e d i r e c t and  format  It  i n d i r e c t p a t i e n t costs  identified  and  of a l l o c a t i o n between departments r e l a t e d to the amount of  a basis  services  31 r e n d e r e d to each.  This process allows i n d i r e c t costs  to d i r e c t p a t i e n t  allocated  c a r e to e n s u r e t h a t a l l components p r o v i d i n g  to the p a t i e n t a r e  work u n i t .  to be  covered by  Evans and  the u n i t c o s t of t h a t p a t i e n t 32  Robinson  r e f i n e d t h i s t e c h n i q u e by  simultaneous equations that allow  service/  developing  f o r the a l l o c a t i o n of s e r v i c e s  departments t h a t s e r v e each o t h e r . used i n t h i s r e p o r t  service  to i d e n t i f y the  This  from  i s . t h e methodology t h a t w i l l  be  c o s t s of the work u n i t s of each  d i r e c t p a t i e n t s e r v i c e i n the s t u d y h o s p i t a l , Vancouver G e n e r a l H o s p i t a l . Components of S e r v i c e s The  Affecting Hospital  development of p r e v e n t i v e  care costs  c o u l d be  types of i n j u r i e s , have the h i g h e s t standardize  Costs  programs f o r MVA  victims  f u r t h e r r e f i n e d to f o c u s on  t o reduce h e a l t h  those components, e.g. ,  number of p a t i e n t s , or demographics of p a t i e n t s  i n f l u e n c e on  cost.  Several  which  attempts have been made to  an approach to h o s p i t a l c o s t i n g by a d j u s t i n g  for  differences  33 i n the number and  types of s e r v i c e s a v a i l a b l e  or by  t r y i n g to  incorporate  TT American H o s p i t a l A s s o c i a t i o n , Cost Findings f o r H o s p i t a l s , Chicago, 1957. "^^Evans R.G., and Robinson G.C., E v a l u a t i o n of the Economic I m p l i c a t i o n s of a Day Care Surgery U n i t , Report to C h i l d r e n ' s H o s p i t a l , Vancouver, B.C., 1973. 33 B e r r y R.E., " P r o d u c t H e t e r o g e n i t y and H o s p i t a l C o s t A n a l y s i s , " I n q u i r y , 7-67, March 1970.  -  h o s p i t a l s i z e , u t i l i z a t i o n and  24  -  an i n f l a t i o n a r y f a c t o r i n t o  definition  34 of h o s p i t a l c o s t s o v e r t i m e .  Frank used a v a r i a n c e  to develop an approach to measure c o m p a r a b i l i t y t o t a l cost basis  f o r a l l U.S.  to 1973.  an u n d e r s t a n d i n g of the i n f l u e n c e s on provide  little  accounting  a  These approaches  give  t o t a l h o s p i t a l costs, e s p e c i a l l y  d e f i n i t i o n as  specific patient related services. an a p p r o p r i a t e  between h o s p i t a l s on  non-governmental, n o t - f o r - p r o f i t , s h o r t 35  term, g e n e r a l h o s p i t a l s from 1950  o v e r time, but  a n a l y s i s methodology  to the a c t u a l c o s t  of  A methodology i s needed t h a t r e l a t e s  t e c h n o l o g y to the v a r i o u s  component s e r v i c e s  offered i n a hospital setting. To  ensure r e s o u r c e  needed of how  and  c o s t c o n t r o l , a fundamental u n d e r s t a n d i n g i s  to d e f i n e ,  by h o s p i t a l s .  i n a manageable f a s h i o n ,  T r a d i t i o n a l l y c o s t c o n t r o l has  where w e l l - d e f i n e d  the s e r v i c e s  provided  been s u c c e s s f u l i n s e t t i n g s  s e r v i c e s , w i t h a p r e d i c t a b l e s e t of a s s o c i a t e d  costs,  36 are p r o v i d e d . h o s p i t a l cost. using  clinical  T h i s begs the q u e s t i o n  costs  to measure changes i n  Thompson s t a t e d t h a t i f p a t i e n t s c o u l d be and  demographic v a r i a b l e s , t h e r e c o u l d be  d i r e c t r e l a t i o n s h i p between case mix used and  of how  of the h o s p i t a l and  classified developed  a  resources  incurred.^  L a v e J.R., and Lave L.B., Review, 60:379, June 1970.  " H o s p i t a l Cost Functions,"  American Economic  35 F r a n k W.G., "A M a n a g e r i a l A c c o u n t i n g A n a l y s i s of H o s p i t a l C o s t s , " Health S e r v i c e s Research, Spring 1976. 36 Thompson J.D., "On Reasonable Cost of H o s p i t a l S e r v i c e s , " M i l l b a n k M e m o r i a l Fund Q u a r t e r l y , 46(1):33 January 1968, P a r t 2. 37 Thompson J.D., A v e r i l l R.F., and F e t t e r R.B., " P l a n n i n g Budgeting and C o n t r o l l i n g - O n e Look a t the F u t u r e : Case Mix C o s t A c c o u n t i n g , " H e a l t h S e r v i c e s R e s e a r c h , Summer 1979. .  - 25  D i s e a s e c o s t i n g i s one  -  approach to c l a s s i f i c a t i o n of p a t i e n t s ; i t  groups a l l i n p a t i e n t s w i t h l i k e d i s e a s e s  or h o s p i t a l p r o c e d u r e s ,  e.g.,  38 hysterectomy, g a l l b l a d d e r s u r g e r y , et c e t e r a , c o s t i n g r e f l e c t s an average of the c o s t s a l l patients with l i k e diseases of p r o v i d i n g  i n one  i n one  c a r e to i n d i v i d u a l p a t i e n t s  those i n the d i s e a s e  between h o s p i t a l c e n t r e s s i m i l a r , and  t h a t the  group.  correct.  the  consequence  i s not a p p a r e n t , e.g.,  of  costing results  assume that, the p a t i e n t p o p u l a t i o n s  comparison of the d i s e a s e  the  t o the a v e r a g i n g  Comparisons of d i s e a s e  d i r e c t measure of the q u a l i t y of c a r e ;  disease  hospital setting for  time p e r i o d ,  i n d i v i d u a l s e v e r i t y of the p a t i e n t i s l o s t due all  but because  are  cost i s , i n fact, a  t h i s assumption i s not  necessarily  Another more s o p h i s t i c a t e d p a t i e n t c l a s s i f i c a t i o n system,  the D i a g n o s t i c R e l a t e d Groups (DRG) system, was developed a t the U n i v e r s i t y Center f o r Health Studies. The DRG approach i s more  Yale  39 meaningful than disease  costing for several  reasons:  a manageable number of patien': c l a s s e s — 3 8 3 DRG's;  •  i t has  •  each DRG  »  the DRG's demonstrate a s t a t i s t i c a l l y s t a b l e d i s t r i b u t i o n of r e s o u r c e uses w i t h i n the u n i v e r s e of p a t i e n t s t r e a t e d by the h o s p i t a l . Thus the DRG's p r o v i d e a means of e s t a b l i s h i n g a . h o s p i t a l case mix by d e t e r m i n i n g the r e l a t i v e number of p a t i e n t s d i s c h a r g e d w i t h i n each d i a g n o s t i c r e l a t e d group.  i s medically  meaningful;  and  38 "Lay C , "What i s D i s e a s e C o s t i n g ? " U n p u b l i s h e d Report, H e a l t h Admini s t r a t i o n , F a c u l t y of A d m i n i s t r a t i o n , U n i v e r s i t y of Ottawa, F e b r u a r y 1974. 39 Thompson e t a l . , o p . c i t . , 37.  - 26  Breaking  -  down a h o s p i t a l ' s o p e r a t i n g budget i n t o d i a g n o s t i c groups  approximates a n a l y z i n g h o s p i t a l c o s t s . u t i l i z a t i o n and  corresponding  Identifying shifts in  b u d g e t a r y changes can g i v e i n s i g h t  b o t h the i n t e n s i t y of c a r e and  t h e fundamental t r e n d s  of the m e d i c a l / s u r g i c a l p r a c t i c e of the h o s p i t a l . ^ may  i n the  in  nature  This last  issue  be more p e r t i n e n t to non-Canadian h o s p i t a l s at t h i s time, as  is l i t t l e  i n c e n t i v e to save b u i l t  there  i n t o most Canadian h o s p i t a l budgets.  As l o n g as t h e s e budgets a r e determined based on h i s t o r i c  utilization,  any  to  h e l p i n making p r o j e c t i o n s which a r e a c c u r a t e  m a n a g e r i a l c o n t r o l s over c o s t s and a s s i s t a n c e to management.  While D i a g n o s t i c R e l a t e d d i s e a s e c o s t i n g and may  provide  reimbursements would be of  great  41  Groupings may  provide better d e t a i l  r e l a t e b e t t e r t o d a t a bases as they  components of t h e ICDA-9 c o d i n g  system, they s t i l l  c o s t i n g i n d i v i d u a l p a t i e n t care. m a t i o n on p a t i e n t s who  enough  Nor  do not  than are  facilitate  do they n e c e s s a r i l y a l l o w  have more than one  disease  infor-  in different  42 d i a g n o s t i c r e l a t e d groups. supply  Lynch  found t h a t the d a t a base c o u l d  p a t i e n t - r e l a t e d i n f o r m a t i o n on more than one DRG  p a t i e n t a b s t r a c t i n f o r m a t i o n , c o u l d not to r a n k which group had hospital  but,  i d e n t i f y a weighting  the most impact on the p a t i e n t ' s use  using system of  resources.  —Bowman R., "DRG's Help T r a c e Revenue S o u r c e s , " Modern H e a l t h J a n u a r y 1980. 41  Care,  Thompson e t a l . , o p . c i t . , 3 7 .  Lynch T., "Report to t h e I n f o r m a t i o n Systems S t e e r i n g Committee of O n t a r i o M i n i s t r y of H e a l t h , " O n t a r i o H o s p i t a l A s s o c i a t i o n , October 20,  1978.  - 27  O t h e r s have t r i e d by  analyzing  to d e v e l o p l e s s demanding s u r r o g a t e s f o r case  o t h e r c h a r a c t e r i s t i c s l e s s d e t a i l e d than  c l a s s i f i c a t i o n and  have found t h a t  s e r v i c e s , and  teaching  mix  e x p l a i n too  but  -  could  A3  of s a t i s f a c t o r y use. h o s p i t a l , e.g.,  mix  patient  " s i z e , number o f f a c i l i t i e s  and  s t a t u s of a h o s p i t a l " a r e c o r r e l a t e d t o case s m a l l a p o r t i o n of the v a r i a t i o n to  be  F e l d s t e i n used i n p a t i e n t components o f  m e d i c a l and  s u r g i c a l care,  f o r a n a l y s i s of  a  cost  . . 44 variation.  45 J e f f e r s and be  Siebert  felt  t h a t none of t h e s e approaches a l o n e would  b e n e f i c i a l i n e x p l a i n i n g v a r i a t i o n i n c o s t s , e s p e c i a l l y among  or more h o s p i t a l s .  They added s e r v i c e i n t e n s i t y ( E l n i c k i d e f i n e d  as a measure of the  q u a n t i t i e s or volumes of o u t p u t s from  departments consumed e i t h e r d i r e c t l y or i n d i r e c t l y by  the  two this  various patient/  46 physician) identify  and  input  p r o d u c t i v i t y f a c t o r s to c a s e mix  the v a r i a b l e s t h a t a f f e c t h o s p i t a l c o s t .  s e r v i c e i n t e n s i t y accounted f o r as g r e a t in  c o s t per  case as  did using  s e r v i c e i n t e n s i t y was  input  further  They found t h a t  a proportion  p r i c e s , and  to  of the  gross  increases  they concluded  that  a major i n f l u e n c e a f f e c t i n g the u p g r a d i n g of  tech-  n o l o g y and o v e r a l l attempts to improving q u a l i t y and p a t i e n t c a r e . A3 Lave J.R., and Lave L.B., "The E x t e n t of Role D i f f e r e n t i a t i o n Among Hospitals," Health S e r v i c e s R e s e a r c h, S p r i n g 1971. ^ F e l d s t e i n M., " H o s p i t a l C o s t V a r i a t i o n and Case Mix D i f f e r e n c e s , " M e d i c a l Care, 3, 95-103, A p r i l - J u n e 1965. ^ J e f f e r s J.R. , and S i e b e r t C D . , "Measurement o f H o s p i t a l C o s t V a r i a t i o n . Case Mix S e r v i c e I n t e n s i t y and Input P r o d u c t i v i t y F a c t o r s , " H e a l t h S e r v i c e s R e s e a r c h, Winter 1974. 46 E l n i c k i R.A., Health Services  " H o s p i t a l P r o d u c t i v i t y , S e r v i c e I n t e n s i t y and Research, Winter 1974.  Cost,"  - 28  Combining s e r v i c e i n t e n s i t y  (i.e.,  -  a l l o c a t i o n of h o s p i t a l r e s o u r c e s )  a measure of the s e v e r i t y of the p a t i e n t ' s i l l n e s s o r i n j u r y should duce a s a t i s f a c t o r y approach to measuring h o s p i t a l c o s t s . a c l a s s i f i c a t i o n of case mix,  a  pro-  S e v e r i t y , as  allows:  a s i m p l e method of grouping p a t i e n t s who different  and  (and thus c l a s s i f i e d  may  be a n a t o m i c a l l y  i n d i f f e r e n t DRG's) but have a  comparable s e v e r i t y of i l l n e s s o r  injury  and •  a l l o w s f o r p a t i e n t s w i t h m u l t i p l e i l l n e s s e s who to group  (as n o t e d  earlier  are  difficult,  i n the r e v i e w of R i c e ' s r e s e a r c h ) .  - 29 -  S e v e r i t y Measurement Throughout most o f the l i t e r a t u r e , a v a i l a b i l i t y o f d a t a i s a c r i t i c a l issue.  The c o s t o f a c c e s s  detail,  e.g., i n d i v i d u a l p a t i e n t s u r v e y s , may outweigh the q u a l i t y of  results.  to d a t a , w i t h  the a p p r o p r i a t e l e v e l o f  I n f o r m a t i o n can be taken d i r e c t l y from p a t i e n t c h a r t s ,  e s p e c i a l l y now t h a t so much i n f o r m a t i o n i s s t o r e d u s i n g d i s e a s e c l a s s i f i c a t i o n systems. s u r g e r y were attempted  Two approaches t o measuring outcomes o f by the s t a f f o f S t a n f o r d Center f o r H e a l t h  47 Care Research:  one was an i n t e n s i v e study w i t h t r a i n e d  i n t e r v i e w i n g p a t i e n t , surgeon,  a n a e s t h e t i s t , and nurse  p a t i e n t c l a s s i f i c a t i o n d a t a ; the p a r a l l e l study used from P.A.S. were s i m i l a r .  be used While  personnel  to c o l l e c t  summary data  Despite the d i f f e r e n c e s i n source data, the r e s u l t s The s t a f f c o n c l u d e d  t h a t h o s p i t a l a b s t r a c t d a t a can 48  to measure the q u a l i t y of s u r g i c a l c a r e i n h o s p i t a l s .  such r e s e a r c h i s b e n e f i c i a l f o r measuring q u a l i t y o f c a r e and  f o r showing t h a t a b s t r a c t i n f o r m a t i o n has u s e f u l p r e d i c t i v e powers, its  c o n t r i b u t i o n t o case mix i s l i m i t e d  similar quality.  I t does n o t show a matching between work u n i t s o f  the h o s p i t a l and p a t i e n t c l a s s i f i c a t i o n . quality into  t o r a n k i n g h o s p i t a l s of  What i s needed to b a l a n c e  of outcome i s a q u a n t i t a t i v e e v a l u a t i o n o f p a t i e n t s coming  the system; t h i s would a s s i s t i n t h e a l l o c a t i o n of r e s o u r c e s and  would p e r m i t comparisons o f h o s p i t a l s i n t h e i r use o r a l l o c a t i o n o f resources. S t a n f o r d Center f o r H e a l t h Care R e s e a r c h , "Comparison o f H o s p i t a l s w i t h Regard t o Outcomes o f S u r g e r y , " H e a l t h S e r v i c e s Research, Summer 1976. f  ^ S t a n f o r d C e n t e r f o r H e a l t h Care Research,  Ibid.,47  - 30 -  The  u b i q u i t y o f statements emphasizing the need f o r r e f i n e m e n t o f 49 50  emergency h o s p i t a l r e c o r d s  f o r MVA v i c t i m s  '  r e v e a l s the i n a d e -  quate s t a t e o f d a t a c o l l e c t i o n and d a t a development f o r MVA. times o f c o n s t r a i n t i t w i l l be o n l y e n t l y a v a i l a b l e resources organization  through b e t t e r u t i l i z a t i o n o f p r e s -  t h a t any improvements c a n be e f f e c t i v e i n the  o f t h e h e a l t h / h o s p i t a l s e r v i c e s t o MVA and o t h e r  p a t i e n t s , commonly c a l l e d  Evaluation  I n these  t h e Emergency M e d i c a l  System  emergency  (EMS).  o f such a system o r f o r t h a t matter any l a r g e  organizational  s t r u c t u r e , r e q u i r e s q u a n t i t a t i v e t o o l s which support a n a l y t i c a l such as computer s i m u l a t i o n and m o d e l l i n g . composed o f s e v e r a l s u b s e c t i o n s  approaches  As w e l l , s i n c e the EMS i s  ( i . e . , the automobile crash;  on s i t e  t r e a t m e n t ; ambulance s e r v i c e ; emergency department s e r v i c e s ; acute treatment and p o s t - a c u t e c a r e treatment) t h e r e o u t p u t d e s c r i p t o r s f o r each s u b s e c t i o n Thus any change i n the EMS (e.g.,  care  i s a need f o r i n p u t and  t o m o n i t o r a l l EMS programs.  i n t r o d u c t i o n of a preventive  program  52 to reduce t h e second c o l l i s i o n for  i n j u r y , must be a n a l y z e d  the EMS.  by i t s i n f l u e n c e a c r o s s  a l l subsections  of  this variable.  . . . Noble J . e t a l . , Emergency M e d i c a l S e r v i c e s : Behavioural P e r s p e c t i v e s , New York, B e h a v i o u r a l P u b l i c a t i o n s , 1973.  "^Boyd D.R., Lowe R . J . and Baker R.J., Method f o r M u l t i f a c t o r i a l E v a l u a t i o n JAMA V o l . 223:422, 22 Jan. 1973.  Haddon W.,  op.cit.,2.  . Planning  "Trauma R e g i s t r y New Computer o f Major H e a l t h Problems,"  "^Cowley R.A., Hudson F. and S c a n l o n E., "A P r o g n o s t i c Trauma," J o u r n a l o f Trauma, December 1974. 52  victims' potential  S e v e r i t y can meet b o t h o f t h e s e c r i t e r i a as a r e s u l t o f r e c e n t  attempts t o q u a n t i f y 49  ) oriented to reducing  Index f o r Severe  - 31 -  Baker  53  suggests t h a t  the s e v e r i t y of the i n j u r y , which c o r r e l a t e s w i t h  the l i f e - t h r e a t e n i n g p o t e n t i a l of the i n j u r y , i s the l o g i c a l to d e f i n e and a n a l y z e the v a r i o u s system.  subsections  descriptor  o f the emergency m e d i c a l  Ogawa and Sugimoto a l s o agree t h a t s e v e r i t y i s a good d e s c r i p t o r 54  of p a t i e n t s , e s p e c i a l l y those u s i n g  the EMS.  They reviewed the  p o t e n t i a l of i n c o r p o r a t i n g a s e v e r i t y r a t i n g s e r v i c e w i t h i n  the EMS  f o r ambulance a t t e n d a n t s t h a t would a s s i s t i n d e l i v e r i n g the a p p r o p r i a t e care  t o the v i c t i m i n the minimum amount of time.  E a r l i e r i t was  suggested t h a t s e v e r i t y would be an e x c e l l e n t m o d i f i e r  t o case mix i n  a n a l y s i s of varying h o s p i t a l costs.  Combining p a t i e n t s i n t o groups on t h e b a s i s of s e v e r i t y of i n j u r y the use of such s c a l e s as A b b r e v i a t e d  requires  I n j u r y S c a l e ^ ^ ( A I S ) and the  56 Comprehensive I n j u r y S c a l e provide crashes.  (CRIS).  These s c a l e s were developed t o  a method f o r r a t i n g and comparing i n j u r i e s  i n c u r r e d i n automobile  Both p e r t a i n t o i n d i v i d u a l i n j u r i e s b u t the AIS i s the s i m p l e r  of the two and thus more w i d e l y used. anatomical categories, or p e l v i c c o n t e n t s ,  The body i s d i v i d e d i n t o s i x  s p e c i f i c a l l y head o r neck, f a c e , c h e s t ,  extremities  or p e l v i c g i r d l e and g e n e r a l .  abdominal Injuries  53 Baker S.P., O ' N e i l l B. and Haddon W., "The I n j u r y S e v e r i t y Score - A Method f o r D e s c r i b i n g P a t i e n t s w i t h M u l t i p l e I n j u r i e s and E v a l u a t i n g Emergency care," J o u r n a l o f Trauma, March 1974. 54 Ogawa M. and Sugimoto T., " R a t i n g S e v e r i t y o f the I n j u r e d by Ambulance A t t e n d a n t ; F i e l d Research o f Trauma Index," J o u r n a l o f Trauma, Nov. 1974. "^Committee on M e d i c a l A s p e c t s of Automotive S a f e t y , " R a t i n g the S e v e r i t y of T i s s u e Damage I The A b b r e v i a t e d I n j u r y S c a l e , " JAMA, January 11, 1971 Vol.215, No.2. "^Committee on M e d i c a l A s p e c t s o f Automotive S a f e t y , " R a t i n g the S e v e r i t y of T i s s u e Damage I I The Con; r e h e n s i v e I n j u r y S c a l e , " JAMA, May 1, 1972, Vol.220, No.5.  - 32  i n each c a t e g o r y  -  were c a t e g o r i z e d u s i n g  the same n u m e r i c a l  system f o r s e v e r i t y (1 = minor, 2 = moderate, 3 = s e v e r e , threatening, critical,  4 = severe l i f e  not  s u r v i v a l probable,  life  5 =  survival uncertain).  The A.I.S. i s of v a l u e i n only  threatening  ranking  one  f o r measuring s e v e r i t y of v i c t i m s w i t h  of the s i x a n a t o m i c a l  v i c t i m s of MVA  have more than one  i n j u r i e s per p a t i e n t .  5 7  The  injuries  categories.  Most h o s p i t a l i z e d  i n j u r y , with  the average b e i n g  a u t h o r s of the A.I.S. c a u t i o n  a v e r a g i n g A.I.S. r a t i n g s f o r each body r e g i o n as "the r e l a t i o n s h i p of the A.I.S. code i s not known and  1.6  against  quantitative  i s almost  certainly  ..58 non-linear.  Baker e t a l . used a q u a d r a t i c scores  r e l a t i o n s h i p between the  ( i . e . , squared the h i g h e s t  category  and  They l i s t e d  i n a d d i t i o n the top t h i s new  top t h r e e A.I.S.  s e v e r i t y s c a l e w i t h i n each body three scores  from d i f f e r e n t body  score f o r patients with m u l t i p l e i n j u r i e s  areas).  against  59 m o r t a l i t y r a t e s and  found s i g n i f i c a n t  S e v e r i t y S c a l e " was  d e f i n e d as  correlation.  This  "Injury  the sum ^of the squares of the  A.I.S. grade i n each of the t h r e e most s e v e r e l y  i n j u r e d body  highest areas.^  "Moylan J.A., Detmer D.E., and Rose J . . " E v a l u a t i o n of the Q u a l i t y of H o s p i t a l Care f o r Major Trauma," J o u r n a l of Trauma, Vol.16 #7, J u l y 1976. 58 "Baker S.P., O ' N e i l l B., Haddon W., and Long W.B., "The I n j u r y S e v e r i t y Scale: Development and P o t e n t i a l U s e f u l n e s s " P r o c e e d i n g s of the 18th Conference of the American A s s o c i a t i o n f o r Automobile M e d i c i n e . Lake B l u f f , 111. AAAM 1974.. 59 Baker et a l . , i b i d . , 6 0  B a k e r e t al.»  ibid.,  58. 58.  -33-  Semmlow"' ' compared h i s r e s u l t s w i t h those of Baker and demonstrated 1  remarkable s i m i l a r i t y  d e s p i t e the complete independence of the d a t a .  He a l s o showed t h a t I.S.S. measurements had a s t r o n g l i n e a r  relation-  s h i p w i t h i n t e r m e d i a t e EMS system v a r i a b l e s such as l e n g t h o f s t a y and need f o r s u r g i c a l p r o c e d u r e s ,  e s p e c i a l l y a t t h e lower  end o f the  I.S.S.  Semmlow J . L . and Cone R., " U t i l i t y o f the I n j u r y S e v e r i t y Score: A C o n f i r m a t i o n , " H e a l t h S e r v i c e s Research, S p r i n g 1976.  - 34 -  III.  METHODOLOGY  B e f o r e any r e l a t i o n s h i p between s e v e r i t y and c o s t can be e s t a b l i s h e d , the s e r v i c e s a v a i l a b l e a t t h e h o s p i t a l and t h o s e used by t h e MVA v i c t i m s must be i d e n t i f i e d . a methodology r e g a r d i n g one  As t h i s paper i s an e x e r c i s e i n d e v e l o p i n g  c o s t of h o s p i t a l s e r v i c e s f o r MVA v i c t i m s ,  h o s p i t a l was used to d e t e r m i n e t h e v a l u e  Vancouver G e n e r a l was s e l e c t e d :  of t h i s methodology.  i t s l a r g e emergency department  indicates a substantial population  o f MVA v i c t i m s .  To  i n t e r - h o s p i t a l r e l a t i o n s h i p s of  t e s t other  only  hypotheses r e g a r d i n g  s e v e r i t y and c o s t , t h e methodology i s t r a n s f e r a b l e to any h o s p i t a l t h a t : •  lists  separation  information  B.C.H.P. s e p a r a t i o n  o f p a t i e n t s as i s done on t h e  t a p e s ; and  • produces y e a r l y H.S.I and H.S.2 forms f o r t h e f e d e r a l government. The  B.C.H.P. s e p a r a t i o n  data,  as they s u p p l y  tapes a r e c r i t i c a l  to the a n a l y s i s of patient  t h e p a t i e n t ' s a d m i s s i o n number  the m e d i c a l r e c o r d number) and o t h e r  pertinent  (thus a c c e s s t o  information r e s u l t i n g  from t h e p a t i e n t ' s s t a y i n t h e h o s p i t a l , such as t y p e o f i l l n e s s or i n j u r y and cause o f i n j u r y .  H.S.I and H.S.2 forms g i v e a l l important  a l l o c a t i o n and budget f i g u r e s f o r t h e major c o s t c e n t r e s  of the h o s p i t a l .  -  Patient  35  -  Data  C r i t i c a l i n f o r m a t i o n on the B.C.H.P. s e p a r a t i o n tapes was coding  of the cause o f the a c c i d e n t  the i n j u r y  ( t h e N code).  s i n g l e d out d u r i n g any  (the E code) and  From the E code, the MVA  the I.CD.A.  the n a t u r e  of  v i c t i m could  be  from the remainder o f the p a t i e n t l o a d of the h o s p i t a l one  year; with  the N code, s e v e r i t y of the p r i m a r y  c o u l d be determined on the A.I.S. s c a l e , u s i n g Baker and mapping of A.I.S. v a l u e s  onto the I.CD.A. codes. ^  i d e n t i f y which l e v e l s of s e v e r i t y were r e p r e s e n t e d  injury  Faigan's  T h i s would i n the  population;  the sampling methodology would ensure r e p r e s e n t a t i o n from a l l l e v e l s .  The  year  1975  and  the H.S.I  was  the l a t e s t y e a r f o r which both.B.C.H.P. s e p a r a t i o n  and  H.S.2  forms were a v a i l a b l e a t the time commencing  r e s e a r c h a t Vancouver G e n e r a l H o s p i t a l . General  H o s p i t a l had  b e i n g MVA  victims.  d r i v i n g or b e i n g  These i n c l u d e d persons i n v o l v e d i n MVA  were s t r u c k by or d i d s t r i k e T h i s f i g u r e of 906  As  t o the h o s p i t a l d u r i n g  t h i s study  victims,  Personal  focusses  i t was  felt  as  while  pedestrians  ( i n the case of  does not r e p r e s e n t  t r e a t e d at Vancouver G e n e r a l H o s p i t a l i n 1975, admitted  and  this  Vancouver  (out of over 50,000 p a t i e n t s ) i d e n t i f i e d  d r i v e n i n a c a r on a p u b l i c road,  o r b i c y c l i s t s who motor v e h i c l e s .  906  For that year,  tapes  a l l MVA  j u s t t h o s e who  bicyclists) victims were  1975.  p r i m a r i l y on the i n p a t i e n t c o s t p a t t e r n s of  t h a t a s i z e a b l e sample of these 906  communications w i t h B a r b a r a F a i g a n ,  June  1977.  MVA  v i c t i m s would  - 36 -  be needed t o g i v e a s i g n i f i c a n t  i n d i c a t i o n of the r e l a t i o n s h i p between  s e v e r i t y and t h e e p i s o d i c h o s p i t a l c o s t s . A.I.S. v a l u e but  906  c o u l d be g i v e n to each p a t i e n t by t h e B.C.H.P.  s i n c e these  locations,  tapes  t o a f f i x an I.S.S. v a l u e  v i c t i m s a t t h i s stage o f the r e s e a r c h .  stratify  tapes;  do n o t denote the top t h r e e i n j u r i e s and  i t was i m p o s s i b l e  values with  As mentioned above, an  on any o f these  A f t e r mapping o f the A.I.S.  the i n j u r i e s o f the 906 v i c t i m s , i t was p o s s i b l e t o  the p o p u l a t i o n t o ensure g e n e r a l  representation of a l l severity  l e v e l s i n t h e sample.  Considering  time c o n s t r a i n t s and t h e demands i n v o l v e d i n d a t a  from m e d i c a l adequate.  r e c o r d s , a 15% sample o f the 906 v i c t i m s was f e l t  collection t o be  C o n s i d e r a t i o n was g i v e n to t a k i n g 15% o f each of the t e n  s t r a t i f i e d groups i n t h e t a b l e below, b u t t h i s would n o t g i v e adequate r e p r e s e n t a t i o n from a l l t e n s t r a t a because l a r g e numbers i n b o t h male and  female would appear i n L e v e l 3, b u t s m a l l r e p r e s e n t a t i o n would be  made i n a l l o t h e r  strata.  be o f l i t t l e v a l u e .  With these  Therefore,  low numbers, a 15% c u t - o f f would  t o ensure good r e p r e s e n t a t i o n o f these  o t h e r groups, a d d i t i o n a l members from each i n d i v i d u a l s t r a t u m  were  chosen randomly t o g i v e t h e f o l l o w i n g breakdown among t h e t e n s t r a t a f o r t h e study  sample.  -  37  -  TABLE C  MVA  Victims By Classification  A.I.S.  A.I.S. Severity Level  Total Population Male  Female  15% Sample Male  Study Sample  Female  Male  Female  1  21  6  3  1  13  6  2  94  49  14  7  23  16  3  397  213  60  31  60  30  4  58  39  8  5  17  14  5  19  10  3  1  13  589  317  88  45  126  Because the o b j e c t i v e of t h i s study was the sampling on sex  and  increase  to determine e p i s o d i c  .  76  cost,  t e c h n i q u e of random s e l e c t i n g from s t r a t a breakdown based  s e v e r i t y d i d not  necessarily influence  the  cost f a c t o r .  An  i n the m a r g i n a l areas of s e v e r i t y s h o u l d ensure b e t t e r  representation  of  the whole p o p u l a t i o n  each s t r a t u m or a c r o s s  the whole p o p u l a t i o n .  s e l e c t e d , each p a t i e n t ' s u s i n g b o t h A.I.S. and c l a s s i f i c a t i o n of  than a 15%  record  sample from  the p a t i e n t .  to I . C D . A . codes p r o v i d e d  across  Once the sample had  been  underwent a complete s e v e r i t y r e v i e w  I.S.S. to determine f i r s t h a n d the Therefore,  10  severity  the mapping of the A.I.S.  an e x c e l l e n t method f o r sample s e l e c t i o n ;  - 38  but  the mapping d i d not  the  evaluation  c a l c u l a t e d by  For  the  202  p r o c e s s of t h i s t h e s i s .  sample MVA  the  first  This  strictly  could  costs  of  These i n c l u d e  i d e n t i f i c a t i o n o f the o n l y be  i d e n t i f y the  i n the  method t h a t  the  direct  nursing  units,  laboratory service  costs  done a f t e r a u n i t p r i c e had  of  each  been  service.  the  services  used i n  i t i s n e c e s s a r y to draw t o g e t h e r the  l i t e r a t u r e , the h o s p i t a l per  specify As  costs.  specif  t h i s purpose,  diem r a t e , an  days, does not level.  For  average  detailed  suggested e a r l i e r  a l t e r n a t i v e i s to develop a step-down  i d e n t i f i e s work u n i t  was  Costs  f i g u r e s , e s p e c i a l l y a t the work u n i t  i n t h i s report,  to  the  and  episodic  t o t a l d o l l a r v a l u e of  victims,  was  examined  o r i g i n a t i n g i n each of  d a i l y v a l u e e s t i m a t e d from p a t i e n t cost  was  the work u n i t s used to t r e a t the p a t i e n t s .  as d e t a i l e d  index  records.  f o r the work u n i t of each d i r e c t p a t i e n t  a h o s p i t a l by MVA  index used i n  t h i s w o r k l o a d f o r each d i r e c t p a t i e n t  I d e n t i f i c a t i o n of D i r e c t P a t i e n t To  severity  types of p r o c e d u r e s i n r a d i o l o g y ,  s t e p i n the  established  The  severity  each m e d i c a l r e c o r d  departments or c o s t c e n t r e s .  Identifying  patient.  victims,  e x t e n t of s e r v i c e s  time i n the OR, tests.  i d e n t i f y the p a t i e n t ' s  the a u t h o r from the p a t i e n t s ' m e d i c a l  determine t h e patient  -  costing  - 39  -  Step-down c o s t a n a l y s i s b e g i n s w i t h a breakdown of the t o t a l of the h o s p i t a l a c r o s s departments/cost departments/cost H.S.2  centres costs.  c e n t r e s to i d e n t i f y  T a b l e D, headed " D i r e c t Expenses," r e c o r d s  f o r 1975.  The  the H.S.2  the t o t a l e x p e n d i t u r e s both  the i n d i r e c t  form on the H.S.2  back to the i n d i v i d u a l  departments.  In a step-down c o s t i n g t e c h n i q u e ,  of the n u r s i n g a r e a s ,  a r e a and  r e c e i v i n g overhead p l a n t overhead  con-  Employee b e n e f i t s a r e r e c o r d e d r e t u r n form and  are not  charged  the a l l o c a t i o n scheme t a k e s the  e x p e n d i t u r e a s s o c i a t e d w i t h t h a t s e r v i c e e s t a b l i s h e d f o r each or overhead  expense  a s s o c i a t e d w i t h wages and  i n the n u r s i n g u n i t s ) .  s e p a r a t e l y i n lump sum  thus  the n u r s i n g u n i t s , i n c l u d e  employee b e n e f i t s ( p r i m a r i l y p e n s i o n  other p a y r o l l deductions  total  indirect  then d i s t r i b u t e s i t t o each f u n c t i o n a l a r e a  services.  F o r example, from T a b l e D,  the  expense i s a l l o c a t e d a c c o r d i n g t o the square  of each department/cost  by  into  i n d i r e c t p a t i e n t s e r v i c e s a r e a s , and  r e q u i r e d f o r h e a t i n g , maintenance, and housekeeping  s a l a r i e s generated  Column (1) of  the o p e r a t i n g expenses  the d i r e c t expense a l l o c a t e d to those u n i t s and  t r i b u t i o n s and  the  i n Table D are d i v i d e d  a s s o c i a t e d w i t h , e.g.,  as w e l l as meals, l i n e n , and  on  the r e p o r t e d e x p e n d i t u r e s  forms and r e f l e c t s  f u n c t i o n a l areas i d e n t i f i e d  d i r e c t p a t i e n t c a r e areas and  individual  T h i s breakdown has been based  r e t u r n of the Vancouver G e n e r a l H o s p i t a l f o r 1975.  f u n c t i o n a l a r e a from  expenditure  c e n t r e ( e x c l u d i n g unassigned  total footage  areas such  as  XABUi. D r  Step-Down Cost  u n c t i o n a l Areas  Plant Overhead  Direct Expense  Plnnt Overhead  2886199.  2945918.10  Equipment Depreciation  1516349.  Employee Benefits  3887679.  Housekeeping  3468471.  67166.93  Laundry/Linen  1643384.  Dietary  7318333.  213579.06  Drugs  2169665.  Medical Supplies  3208240.  Medical Records Nursing Administration  Employee Benefits  HouseKeeping  Laundry/  23351.77  4062530.40  9704.63  211251.58  3698820.30  33208.04  89375.67  110594.55  1964845.10  77030.53  301439.75  268164.05  19648.45  594452.  29164.59  15011.86  39406.54  36618.26  1105786.  68345.30  24109.95  73531.80  85512.50  1634939.  24745.71  108875.81  31070.04  1624970.  26218.67  23655.04  108469.56  32919.45  45191.44  606313.  70112.85  39121.80  3959240.  115185.39  108267.31  263658.22  E.E.G.  203029.  6481.02  7126.84  E.C.G.  557600.  6775.61  7278.48  ICU  553084.  20621.43  14405.32  Renal  869715. 72048.  15613.37 1178.36  20015.81  63612.  589.18  607732.  139047.33  Nursery Rad tology Film  702938.  10605.31  2530973. 260001.  86315.40  136926.31  138938.53  108375.26  Laboratory  5904948.  132271.72  152999.61  319314.88  166076.77  Phys. Med. & Rehab.  1325828.  61569.69  26232.84  87344.40  77305.23  593455.  11489.08  8946.46  39406.54  14425.38  Obs./Cyn-Dellvery  Social Service Motor Service  8197504.00  48523.17  5266896.30  230380.83  1374277.50  49379.21  68769.58  97235.81  164866.19  144623.65  589453.53  419072.00  2041985.60  13812.60  8137.39  1964.85  30062.72  8507.27  2947.27  40219.05  88031.79  48666.11  25891.70 58094.18 4468.78  19603.72  1625.01  739.76  87344.40  174584.04  196549.76  773823.73  1320748.80  33785511.00  4010112.70  37795623.00  54303.42  82603.04  2212575.00  262576.80  2475151.80  271517.10  57768.14  1359803.50  161202.20  1521005.70  280742.35  7922228.10  940623.20  8862851.30  240551.70  28251.90  268803.60  613171.36  73122.70  686294.10  81255.48  16556.60  760480.64  90572.40  851053.00  236308.21  32933.24  1448833.20  172004.40  1620837.60  79174.67  9140.33  66565.95  7893.92  74460.00  1057230.90  125421.82  1182652.70  1479.53  13315.73 4912.11  63.28  3929.69  1177.62  4680683.  332888.74  159974.81  240908.05  417966.04  General Administration  6817411.  179995.59  77333.80  342877.56  225997.57  474643.  21799.79  22138.70  30875.23  27371.23  8278.30 1125825.34 50824.52  Grandvlew Nursing Home Total  86417.68  813276.70  356472.92  3362913.50 (260001.00)  6675611.00  . 791885.08  7467466.10  1583450.70  187792.26  1771243.00  667722.50  78939.23  746661.70  to Gen.Admin.  6049634.30  717931.49  7651893.90  to Gen.Admin.  1707756.20 50824.52  202749.17 5816.57  2945918.10  1516500.50 (.0099X) error  4062936.60 (.0099X) error  3698814.40  1964845.15  5317720.80 (2879784) To employees' meals t  3925778.10 (.0099X) error  1357585.60  1799630.30 '(78323320.00)  6767565.80 1910505.40 56641.10  to Gen.Admin. (384922.00)  fo84922.00)  384922. 81848791.  726859.04  40727.57  Service to Community Medical Staff  88315.00  3006440.60 *260001.0O  616770.80  38187.79  578583.  Education Pharmacy  General Admin.  1799630.50 1218203.90  Psychology  Sub-Total  1357585.60  1526870.60  Audiology  Nursing Admin.  3925385.70  1333728.70  OR - PAR  Hedleal  fesax&a.  2169665.00  481137.53  O.P.D.  Hed.Supplies t CSR  (9824.23)  1216074.90  Emergency  Drugs  (59719.20)  19043366.  Nursing Units  Dietary  Linen  1516349.00  88082.95  C.S.R.  Equipment Depreciation  Allocation  8308925.80  *78323320.00  excluded from Gen. Admin, allocation  tt  - 41 -  c o r r i d o r s and s t a i r s ,  or areas a s s i g n e d t o p l a n maintenance  o p e r a t i o n ) as r e p o r t e d i n A l l o c a t i o n Formula A.  A difficulty services  a r i s e s because  to each o t h e r .  indirect patient  (See page 42).  s e r v i c e areas supply  P l a n t Overhead, f o r example,  h e a t i n g and maintenance f o r the D i e t a r y and Laundry these departments  supply s e r v i c e s  and  includes  areas, while  to P l a n t Overhead i n t h e form of  employee meals and employee uniforms r e s p e c t i v e l y .  The u s u a l  p r o c e d u r e i n step-down t e c h n i q u e i s to a r r a n g e a r e a s i n a h i e r a r c h i c a l o r d e r and t h e n a l l o c a t e a r e a s s u p p l y i n g s e r v i c e s  to o t h e r s but  r e c e i v i n g none i n r e t u r n , t o s e r v i c e s lower i n the o r d e r and closing  then  down these a r e a s , h a v i n g a l l o c a t e d a l l the departments'  a c r o s s o t h e r d i r e c t p a t i e n t c a r e departments  or c o s t c e n t r e s .  done, these i n d i r e c t p a t i e n t s e r v i c e s can be c o n s i d e r e d f u l l y and  the next s t e p i s to d e v e l o p work u n i t  costs Once  allocated  c o s t s f o r each d i r e c t  patient  service.  The problem w i t h t h i s approach  i s t h a t the m a t r i x i s not  hierarchical.  F o r example, P l a n t Overhead accounts f o r a p o r t i o n of employee b e n e f i t s a s s o c i a t e d w i t h the s a l a r i e s of p l a n t and maintenance But employee b e n e f i t s i n c l u d e p h y s i c a l f a c i l i t i e s  such as lounges  l o c k e r rooms and lunchrooms which generate p l a n t overhead These same a r e a s a l s o g e n e r a t e housekeeping of housekeeping  workers.  expense.  expenses w h i l e the  p e r s o n n e l generate employee b e n e f i t s .  and  salaries  To complete  this  - 42 -  ALLOCATION FORMULA "A" SQUARE FOOTAGE OF FLOOR AREA %  Nursing Units Nursing Administration Renal ICU EEG ECG Psychiatry Audiology Nursing Obs/Gyn OR-PAR Emergency Outpatient Department Physical Medicine Laboratories Radiology Pharmacy Social Services Dietary Laundry C. S •R• Employee Benefits Medical Records Education General Administration Central Stores Building Maintenance Housekeeping Stair Corridors, Elevators  466,261 9,509 6,025 7,962 2,450 2,560 227 453 4,075 53,312 44,046 10,009 26,898 23,562 50,710 33,054 8,367 4,361 81,901 33,809 11,227 25,745 26,233 127,634 68,953 1,129,443 34,985 145,484 263,738  41.28 .84 .53 .70 .22 .23 .02 .04 .36 4.72 3.91 .89 2.38 2.09 4.49 2.93 .74 .39 7.25 2.99 .99 2.28 2.32 11.30 6.11 100 not a l l ocated  - 43 -  i n t e r c o n n e c t i o n , t h e l a u n d r y and l i n e n a r e a s u p p l i e s s e r v i c e t o both Housekeeping  and D i e t a r y a r e a s , w h i l e Housekeeping  s u p p l i e d t o b o t h L a u n d r y / L i n e n and D i e t a r y . overhead  services are  A l l areas generate  plant  expense and a l l s a l a r i e s g e n e r a t e employee b e n e f i t s ,  completing  the i n t e r a c t i o n between these s i x departments.  Only the  e x p e n d i t u r e s a s s o c i a t e d w i t h equipment d e p r e c i a t i o n a r e i s o l a t e d a l l other i n d i r e c t p a t i e n t areas.  from  S e r v i c e areas w i t h l a r g e amounts  of equipment may g e n e r a t e s i g n i f i c a n t d e p r e c i a t i o n expense, b u t the d e p r e c i a t i o n items g e n e r a t e no e x p e n d i t u r e i n r e t u r n .  T h i s problem  of simultaneous  f l o w back and f o r t h between these  s e r v i c e s i s r e s o l v e d by s e t t i n g up a b l o c k of s i m u l t a n o u s that allows, i n e f f e c t , departments  equations  the c l o s i n g down o f a l l i n t e r l o c k i n g  a t one time.  Each overhead  area i s a l l o c a t e d ,  overhead  following  2  the same p r o c e s s o u t l i n e d i n Evans and Robinson.  A l l o c a t i o n o f Overhead Departments P l a n t Overhead e x p e n d i t u r e s ( p l u s a share of employee b e n e f i t s ) a r e a l l o c a t e d a c c o r d i n g to A l l o c a t i o n Formula s c h e d u l e , t h e apportionment departments  "A," page 42.  o f f l o o r a r e a accounted  excludes non-assigned  space  ( s t a i r s and e l e v a t o r s ) p l u s  the e f f e c t o f s p r e a d i n g the c o s t o f these n o n - a s s i g n e d  Evans R.G., and Robinson  this  f o r by f u n c t i o n a l  c e n t r a l s t o r e s and b u i l d i n g maintenance and housekeeping.  i n c l u d e d f u n c t i o n a l departments  From  T h i s has  areas over t h e  i n p r o p o r t i o n t o t h e square f o o t a g e  G.C., o p . c i t . , 32.  - 44 -  allocated are  each department.  The p r o p o r t i o n s c a l c u l a t e d  i n A l l o c a t i o n "A"  then m u l t i p l i e d by $2,945,918.00 t o a r r i v e a t the e n t r i e s  (2) o f T a b l e D. these e n t r i e s  Small deviations  i n Column  i n p e r c e n t a g e between t h e t o t a l o f  ( l a s t l i n e ) and t h e i n d i v i d u a l f i g u r e s  due  to round-off  The  a l l o c a t i o n f o r m u l a f o r major d e p r e c i a t i o n ,  to be a l l o c a t e d a r e  error.  A l l o c a t i o n Formula "B",  page 45, i s more complex to d e v e l o p .  The d o l l a r v a l u e from the H.S.2  return  i s a p e r c e n t a g e of t h e t o t a l  f o r Vancouver G e n e r a l H o s p i t a l  y e a r ' s e x p e n d i t u r e which i s then a l l o c a t e d t o a l l b u i l d i n g s ment on the campus of the h o s p i t a l . depreciation The  the d e p r e c i a t i o n  equipment s h o u l d c a r r y depreciation  s h o u l d be a l l o c a t e d  shows b u i l d i n g a t $485,962.00.  i d e n t i f y e i t h e r which t o o r which p i e c e s o f  the equipment d e p r e c i a t i o n  f i g u r e was a l l o c a t e d  a square f o o t a g e b a s i s ,  costs.  The b u i l d i n g  t o a l l departments/cost c e n t r e s on  as i d e n t i f i e d i n A l l o c a t i o n Formula  equipment d e p r e c i a t i o n  allocated  return  a t $1,030,387.00 and equipment d e p r e c i a t i o n  h o s p i t a l was not i n a p o s i t i o n t o f u r t h e r  buildings  The  The H.S.2  and e q u i p -  "A."  needed more d e f i n i t i o n b e f o r e i t c o u l d  a c r o s s the departments.  be  I t was d e c i d e d t o average t h e  equipment expense o f each department/cost c e n t r e over t h e l a s t  three  y e a r s , 1973, 1974 and 1975,to determine each department's share o f c a p i t a l e x p e n d i t u r e s by the h o s p i t a l .  This  p e r c e n t a g e f i g u r e f o r each  department i s seen i n Column (2) of A l l o c a t i o n Formula "B."  The  - 45 -  ALLOCATION FORMULA " B "  Nursing U n i t s Renal ICU EEG ECU OR/PAR Obs/Gyn Emergency Physical Medicine OPD Lab X-ray Pharmacy Soc. S e r v i c e s Dietary Housekeeping Laundry C.S.R. Emp. B e n e f i t s Medical Record Education Gen. A d m i n .  Building Depreciation Allocation  Equipment  $1,030,387.  P e r c e n t a g e of C a p i t a l Cost  432,556.46 5,461.05 7,212.71 2,266.85 2,369.89 40,185.09 48,531.23 9,067.41 21,432.05 24,523.21 46,161.34 30,087.30 7,624.86 4,018.51 74,600.02 7,212.09 30,808.57 10,200.83 23,389.78 24,111.06 116,227.65 62,750.56  i  1 1 ' 1  Depreciation U.S.2 V a l u e $485,962.  10% 3% •1.5% 1% 1% 14%  48,596 .20 14,528 .80 7,264 . 4 0 4,859 .62 4,859 .62 68,034 . 6 8  3% 1% 3% 22% 22% 3% 1% .5% .5% .5% 1%  1 4 , 5 2 8 .80 4 , 8 5 9 62 1 4 , 5 2 8 80 1 0 6 , 9 1 1 64 1 0 6 , 9 1 1 . 64 1 4 , 5 2 8 . 80 4 , 8 5 9 . 62 2 , 4 2 9 . 81 2 , 4 2 9 . 81 2 , 4 2 9 . 81 4 , 8 5 9 . 62  9% 3%  4 3 , 7 3 6 . 58 1 4 , 5 2 8 . 80  Total 481,152.66 19,989.85 14,477.11 7,126.47 7,229.51 108,219.77 48,531.23 23,596.21 26,291.67 39,052.01 153,072.98 136,998.94 22,153.66 8,878.13 77,029.83 9,642.52 33,238.38 15,060.45 23,389.78 24,111.06 159,964.23 77,279.36  Percentage 31.73 1.32 .95 .47 .48 7.14 3.20 1.56 1.73 2.58 10.09 9.03 1.46 .59 5.08 .64 2.19 .99 1.54 1.59 10.55 5.1  - 46 -  ALLOCATION FORMULA "C" EMPLOYEE BENEFITS & SALARIES  %  Nursing Administration Nursing Units (plus students) Psychology Audiology C• S .R• Nursery Obs. Renal OR/PAR Emergency Outpatients Lab ECG EEG Pharmacy Radiology Physical Medicine Social Services Education Dietary Laundry Housekeeping Motor Services Plant Operation and Maint. Medical Records and Library General Administration  1,632,422  2.68  19,998,205 24,236 66,441 593,554 1,310,670 869,449 3,952,597 1,624,565 600,422 4,789,147 451,222 204,122 462,896 2,085,958 1,309,039 592,511 3,612,207 4,517,857 1,343,287 3,165,414 574,118 897,832 1,104,128 5,139,652  32. 83 04 11 97 2.15 1.43 6.49 2.67 . 99 7.86 74 34 76 3.42 2.15 97 5.93 7.42 2.20 5.20 , 94 1.47 1.81 8.44  60,921,951  100. 01  - 47 -  i n d i v i d u a l p e r c e n t a g e s were then a p p l i e d t o t h e equipment  depreciation  c o s t o f $485,962.00, to a l l o c a t e the t o t a l c o s t among the member departments/cost centres. depreciation costs  The b u i l d i n g d e p r e c i a t i o n and equipment  f o r each department were then added t o g e t h e r t o  determine the d e p a r t m e n t a l s h a r e of t o t a l d e p r e c i a t i o n o f the h o s p i t a l . T h i s i s o u t l i n e d i n Column (4) o f A l l o c a t i o n Formula "B."  Employee b e n e f i t s i n c l u d e d  $3,887,679.00 o f d i r e c t expense f o r Vancouver  G e n e r a l H o s p i t a l on b e h a l f  of i t s s t a f f ,  housekeeping c o s t s use  as w e l l as p l a n t overhead and  f o r a r e a s of the h o s p i t a l d e s i g n a t e d  and t h e d e p r e c i a t i o n o f these a r e a s .  been a l l o c a t e d a c c o r d i n g  f o r employee  A t o t a l o f $4,062,530.40 has  t o A l l o c a t i o n Formula "C," which i s the s h a r e  of each f u n c t i o n a l department i n the t o t a l h o s p i t a l wage and s a l a r y payments.  The f i n a l d o l l a r f i g u r e f o r employee b e n e f i t s i s found i n  Column ( 4 ) , top l i n e i n T a b l e D.  Housekeeping c o s t s were c a l c u l a t e d f rom the t o t a l of d i r e c t expense of $3,468,471.00 from the H.S.2 r e t u r n p l u s d e p r e c i a t i o n , and  a p o r t i o n of laundry  totalling  $3,608,820.30.  T a b l e D, a c c o r d i n g  employee b e n e f i t s  and l i n e n expenses f o r maintenance o f u n i f o r m s , This  t o t a l i s a l l o c a t e d i n Column (5) of  t o Schedule "A," h o s p i t a l f l o o r  area.  Laundry and l i n e n s e r v i c e s c o s t $1,964,845.10, comprised o f a d i r e c t expense o f $1,643,584.00 p l u s employee b e n e f i t s , p l a n t  overhead,  - 48 -  housekeeping  and  depreciation.  The  appropriate d i s t r i b u t i o n for this  t o t a l would i d e a l l y be by pounds of l a u n d r y p r o c e s s e d f u n c t i o n a l department; s i n c e t h i s i n f o r m a t i o n was e s t i m a t e d a l l o c a t i o n scheme was  f o r each  not a v a i l a b l e ,  constructed i n c o n s u l t a t i o n with  Vancouver G e n e r a l H o s p i t a l ' s l a u n d r y manager. t i o n i s g i v e n i n A l l o c a t i o n Formula "D"  and  This estimated  the r e s u l t i n g  of l a u n d r y expense i s r e c o r d e d i n Column (6) of T a b l e  $7,318,333.00 of d i r e c t expense p l u s p l a n t overhead, laundry s e r v i c e s .  areas, nursing u n i t s , s t a f f  allocation  D.  of  housekeeping,  Meals were s u p p l i e d to t h r e e  c a f e t e r i a s and  i n 1975,  t i o n s o u t s i d e the H o s p i t a l , as i s seen i n the H.S.I  two  other  return.  instituFrom  d i s c u s s i o n s w i t h the a c c o u n t i n g department of Vancouver G e n e r a l the  c o s t of  the s t a f f  staff  meals  c a f e t e r i a by  was  determined  a c c o u n t i n g department and  institutions,  T h i s was  the P r o v i n c e .  the d i e t a r y department would be to the n u r s i n g u n i t s ,  by d i v i d i n g  approved  the  those to two  (the meals other  See Column ( 7 ) , T a b l e D f o r the  d o l l a r breakdown of the d i e t a r y department.  These c o s t s w i l l a l s o be e x c l u d e d  to come  T h e r e f o r e , the r e a l c o s t s of  64.25% of the meals, and  f o r employee meals were e x c l u d e d  from  by both  t h a t which i s not r e c o v e r e d  .61% of t o t a l m e a l s ) .  Hospital,  the revenue  the number of s t a f f meals i n the y e a r ,  up w i t h an average meal c o s t of $1.52.  the  distribu-  D i e t a r y department t o t a l expense of $8,197,504.00 i s comprised  employee b e n e f i t s , and  an  from from  T a b l e D shows t h a t c o s t s  the a l l o c a t i o n of d i e t a r y  expenses.  the c a l c u l a t i o n s of per diem  - 49 -  ALLOCATION FORMULA "D" ESTIMATED DISTRIBUTION OF LAUNDRY & LINEN EXPENSE BY FUNCTIONAL  AREA  % Nursing  Units  OR/PAR  62 30  Emergency  2.3  Outpatient  3.5  Dietary  .1  Rehab and P h y s i c a l M e d i c i n e  .2  Radiology  .25  EEG  •10  ECG  .15  Housekeeping  .5 100.00  - 50 -  c o s t s of a l l h o s p i t a l s e r v i c e s used l a t e r i n t h i s  report.  Drugs, M e d i c a l / S u r g i c a l S u p p l i e s , CSR V.G.H. had, i n 1975, a c o s t c e n t r e a c c o u n t i n g operations. two items,  system f o r t h e i r  internal  T h i s system a i d e d g r e a t l y i n the a l l o c a t i o n o f the next drugs and CSR.  Column  (8), Table  D, r e p o r t e d  o n l y the  a l l o c a t i o n o f the c o s t s o f the a c t u a l drugs purchased by V.G.H.  For  example, ward s t o c k t o the n u r s i n g  drugs  u n i t s c o s t $230,380.83 w h i l e  used i n the Pharmacy c o s t $1,125,825.34. expense f o l l o w s  Therefore,  step-down of drug  the d i s t r i b u t i o n i n d i c a t e d i n the c o s t c e n t r e  from V.G.H. as r e p o r t e d  printouts  i n A l l o c a t i o n Formula " E " .  P r e s c r i p t i o n costs f o r patient services provided  by the Pharmacy  will  be reviewed l a t e r i n t h i s c h a p t e r when a u n i t c o s t f o r p a t i e n t p r e s c r i p t i o n s w i l l be d e v e l o p e d .  Overhead c o s t s r e l a t e d to drug  d i s t r i b u t i o n and purchase w i l l be accounted f o r i n the u n i t v a l u e f o r Pharmacy s e r v i c e s , . a s they a r e r e s p o n s i b l e  f o r the management and  d i s t r i b u t i o n o f drug s u p p l i e s .  Rows (9) and (10) of T a b l e D, m e d i c a l / s u r g i c a l s u p p l i e s and c e n t r a l room, e x p e n d i t u r e s T a b l e D. and  were c o n s o l i d a t e d  supply  and a l l o c a t e d i n Column (9) of  The c o s t s i n c l u d e d t h e d i r e c t expenses f o r C.S.R. o p e r a t i o n  f o r the m e d i c a l / s u r g i c a l s u p p l i e s , and t h e i n d i r e c t  associated with  operating  the C.S.R.  costs  ( I t i s p o s s i b l e t o argue t h a t  ALLOCATION FORMULA " E " DRUG EXPENSE FROM THE COST CENTRE PRINTOUT  Nursing Units T o t a l l e d Renal  $  230,380.83 196,549.76  ICU  48,666.11  Emergency  49,379.21  O u t p a t i e n t Department  97,235.81  OR/PAR CSR P h y s i c a l Medicine Pharmacy  419,072.00 2,492.72 63.28 1,125,825.34  -  52 -  s i n c e t h e C.S.R. a l s o handled a share o f drugs, p a r t o f i t s expenses should  be a l l o c a t e d p r o p o r t i o n a l l y t o t h e flow  o f drug expense.  But  t h i s i s such a s m a l l p a r t o f t h e t o t a l t h a t t h e e x t r a g a i n e d i n a c c u r a c y would be t r i v i a l compared to the workload i n v o l v e d . )  As i n  the case of drug expenses, Column (9) i s a l l o c a t e d , u s i n g A l l o c a t i o n Formula "F", which i s based on the p r i n t o u t from the c o s t c e n t r e These c o s t s  included  the m a t e r i a l s  identified  system.  f o r t h e C.S.R. p l u s the  d i r e c t expense from the H.S.2 r e t u r n f o r the C.S.R., the i n d i r e c t overhead expenses and, o f c o u r s e , t h e m e d i c a l / s u r g i c a l  The  medical records  supplies.  department expense t o t a l l e d $1,357,585.60 based  on d i r e c t expense o f $1,105,786.00 and t h e i n d i r e c t overhead Through c o n s u l t a t i o n w i t h the m e d i c a l r e c o r d s  costs.  department d i r e c t o r ,  an e s t i m a t e d d i s t r i b u t i o n of time spent i n t h i s department t o satisfy given  the needs o f o t h e r  f u n c t i o n a l areas was determined.  i n A l l o c a t i o n Formula "G", and the r e s u l t i n g a l l o c a t i o n of  medical record  expenses i s r e c o r d e d  Nursing Administration  i n Column (10) o f T a b l e D.  costs are a l l o c a t e d across  departments by the number o f s u p e r v i s o r s , A t o t a l o f $1,799,630.50 was i n c l u d e d administration  the v a r i o u s  functional  head nurses and t h e i r a s s i s t a n t s .  i n this cost.  Assuming  that  demands a r e comparable f o r each department, t h e v a r i a t i o n  i n demand s h o u l d m i r r o r aspect  T h i s was  of nursing.  t h e number o f p e o p l e r e q u i r e d t o h a n d l e  Therefore,  that  t h i s a l l o c a t i o n as shown i n Column ( 1 1 ) ,  -  53 -  ALLOCATION FORMULA "F" SURGICAL AND OTHER MEDICAL SUPPLIES  Nursing Units OR/PAR  $1,018,321.20  35.01  1,513,314.80  52.02  60,125.29  2.07  Renal  175,076.70  6.02  Emergency  122,187.26  4.20  827.84  0.03  15,438.81  0.53  3,766.24  0.13  2,909,057.90  100.01  ICU  Physical Medicine OPD Pharmacy  CSR  286,552.57 - not allocated  - 54 -  ALLOCATION FORMULA "G" MEDICAL RECORD DEPARTMENT SERVICES  % Inpatient Units  57  Outpatient C l i n i c  17  Emergency Department  4  S u r g i c a l Outpatients  3  Education  8  Research  8  Medical Staff A c t i v i t i e s  3  - 55  T a b l e D,  i s based on  Column (12), T a b l e D,  the A l l o c a t i o n Formula "H",  general  medical s t a f f administration  costs.  The  last  a d m i n i s t r a t i o n , which i n t u r n was  remaining f u n c t i o n a l  The  a l l o c a t i o n f o r m u l a used to d i s t r i b u t e t h i s new based on  a l l o c a t e d budget. s h o u l d be  two  items were  allocated  across  areas.  general  administration  the r a t i o of each department's budget to the To be a c c u r a t e ,  subtracted  percentages are  indirect  a d m i n i s t r a t i o n , motor s e r v i c e  the  c o s t was  56.  S e v e r a l of these can be argued as  patient services, s p e c i f i c a l l y ,  added to g e n e r a l  page  shows a s u b t o t a l f o r those f u n c t i o n a l a r e a s  t h a t remain u n a l l o c a t e d .  and  -  the new  general  administration  from the t o t a l a l l o c a t e d budget b e f o r e  calculated.  N u r s i n g U n i t Budget ( T o t a l A l l o c a t e d Budget - New A d m i n i s t r a t i o n Budget)  33,785,511.00 (78,323,320 - 8,308,925.80)  For  cost  these  example:  General  X  N  e  w  G  e  n  e  r  a  =  l  Admin Budget  X  total  8,308,925.80  =  The s h a r e of new g e n e r a l budget a l l o c a t e d to Nursing U n i t s .  48.26% or $4,010,112.75  - 56 -  ALLOCATION FORMULA "H" NURSING ADMINISTRATION  Functional Area Nursing Units OR PAR Emergency 0. P.D. Renal 1. C.U. General Administration  Number of Administration Staff 160 34 10 7 4 2 1 218  73.39% 15.60% 4.59% 3.21% 1.83% .92% .46% 100  -  As and  57 -  i s noted i n T a b l e D, t h e f u n c t i o n a l a r e a s o f Grandview N u r s i n g Home radiology (1)  f i l m were n o t i n c l u d e d  i n this  last allocation  Grandview N u r s i n g Home was on t h e H.S.2 r e t u r n form f o r Vancouver G e n e r a l H o s p i t a l p u r e l y as an a c c o u n t i n g  operation  and thus had no r e a l  involvement i n Vancouver G e n e r a l day  (2)  Hospital's  t o day o p e r a t i o n s ; and  R a d i o l o g y f i l m i s , l i k e drugs, a p r i m a r y raw m a t e r i a l expense and d i d n o t draw on any s e r v i c e s of t h e H o s p i t a l ; t h o s e s e r v i c e s n e c e s s a r y t o incorporate  radiology  operations,  i . e . , administration,  storage,  f i l m i n t o t h e day t o day maintenance,  e t c . , would be i n c u r r e d by t h e r a d i o l o g y  department as s e e n i n L i n e t o t a l of Column (14)  (24), T a b l e D.  i s less  The  than t h e t o t a l of  Column ( 1 ) , due t o t h e e x c l u s i o n o f the v a l u e s of employees' meals, r a d i o l o g y  f i l m and Grandview  N u r s i n g Home.  were added t o the  I f these v a l u e s  t o t a l of Column (14), $81,848,027.00, o n l y  this  t o t a l would be  .00094% e r r o r .  because:  - 58 -  Unit  Values  The c a l c u l a t i o n of u n i t v a l u e s f o r the r e m a i n i n g f u n c t i o n a l ranges  from e x a c t d i v i s i o n s of the t o t a l d o l l a r v a l u e by  to e s t i m a t e s based departments.  on c o n s u l t a t i o n s  The f o l l o w i n g  w i t h s t a f f of those  is a list  departments  utilization, functional  of the f u n c t i o n a l a r e a s  remaining,  as seen i n Column ( 1 4 ) , T a b l e D .  1. 2. 3. 4. 5. 6. 7. 8. 9.  10. O b s t e t r i c s / G y n e c o l o g y / D e l i v e r y 11. N u r s e r y 12. R a d i o l o g y 13. F i l m 14. L a b o r a t o r y 15. P h y s i c a l M e d i c i n e 16. S o c i a l S e r v i c e 17. E d u c a t i o n 18. Pharmacy  Nursing Units Emergency O p e r a t i n g Room EEG ECG ICU Renal Audiology Psychology  Not a l l f u n c t i o n a l a r e a s p e r t a i n to MVA w i l l be determined victims.  from the a n a l y s i s  The f o l l o w i n g  p a t i e n t s , but those t h a t do  of t h e m e d i c a l r e c o r d s of the MVA  i s a breakdown of the method used  the u n i t v a l u e s o f these f u n c t i o n a l a r e a s .  t o determine  -59-  Nursing  Units  S i n c e s a l a r y and overhead c o s t s a r e stepped-down a c r o s s a l l n u r s i n g units,  the b e s t approach t o d e f i n i n g a u n i t c o s t would be t o i d e n t i f y  the t o t a l p r o p o r t i o n o f r e s o u r c e s care  used by each d i v i s i o n o f n u r s i n g  ( i . e . , m e d i c a l / s u r g i c a l , o b s t e t r i c s , p a e d i a t r i c s , convalescent  and extended c a r e , i n c l u d i n g c h r o n i c c a r e ) .  From T a b l e D, t h e t o t a l  a l l o c a t e d budget f o r n u r s i n g u n i t s i s $37,795,623.00. l a r g e s t component o f t h i s c o s t i s f o r n u r s i n g s a l a r i e s ; d i s t r i b u t i o n of f u l l - t i m e equivalent nursing s t a f f l e v e l s o f c a r e was used t o a l l o c a t e t h e r e s o u r c e s  By f a r the thus the  t o each o f these to a l l nursing u n i t s .  I n 1975 n u r s i n g s t a f f were on a g e o g r a p h i c b a s i s to p a v i l i o n s , r a t h e r than by l e v e l s o f c a r e . allocated  to s h o r t  But the H.S.2 form i d e n t i f i e s n u r s i n g  salaries  term u n i t s ( a d u l t and c h i l d ) and t o l o n g term u n i t s  of $17,250,584 and $1,785,950 r e s p e c t i v e l y .  Without a p a t i e n t  classifi-  c a t i o n system, a b a s i c assumption was made t h a t n u r s i n g FTE's were a l l o c a t e d i n a s i m i l a r manner t o t h e component l e v e l s o f c a r e t h a t were o f f e r e d i n the s h o r t term u n i t .  T h i s assumption was made f o r the two l e v e l s o f  c a r e t h a t were o f f e r e d i n t h e l o n g term u n i t . made t h a t l a b o u r , d e l i v e r y and n u r s e r y  A second assumption was  c o s t s must be added  to t h e o b s t e t r i c s  t o t a l t o ensure t h a t t h e i r o p e r a t i n g c o s t s were i n c l u d e d i n t h i s s t u d y .  Short Term Bed D i s t r i b u t i o n  ( s e t up December 31, 1975)  M e d i c a l / S u r g i c a l beds - 1,218 83.0% P a e d i a t r i c beds  -  O b s t e t r i c beds  -  167 11.3% 83  5.6%  -  60  -  U s i n g t h e s e p e r c e n t a g e s , the n u r s i n g s a l a r i e s f o r s h o r t ($17,250,584) can  be  allocated  -$14,334,662  Paediatrics  -  1,947,834  Obstetrics  -  968,084  -  607,737  -  702,938  Delivery  Nursing  Long Term Bed  Distribution  R e h a b i l i t a t i o n beds Extended  47  16.2%  ( C h r o n i c ) beds - 242  83.8%  U s i n g these f i g u r e s , ($1,785,950) can  be  -  the n u r s i n g s a l a r i e s a l l o c a t e d allocated  Rehabilitation  -$  Extended  - 1,495,501  Medical/Surgical  o f $37,795,623, T a b l e D,  calculated  Salaries  Percentage  14,334,662  70.45%  Allocated  Dollars  $26,627,016  1,947,834  9.56%  3,617,041  Obstetrics  2,278,759  11.20%  4,233,110  Extended  To  get  a d a i l y cost  separation not  (Chronic)  290,449  1.43%  540,477  1,495,501  7.35%  2,777,978  f o r each o f  days f o r 1975  used when the  these l e v e l s of c a r e , t h e i r  were used.  occupancy of any  This of  the  above were used.  Paediatrics  Rehabilitation  units  290,449  d i s t r i b u t i o n of n u r s i n g s a l a r i e s as o f Care  to l o n g term  as:  Thus, t o a l l o c a t e the n u r s i n g u n i t c o s t s  Level  units  as:  Medical/Surgical  Labour and  term  actual  accounted f o r those bed  these u n i t s was  below  100%.  days  - 61 -  Patient form.  separation Intensive  medical/surgical this  Level  days by l e v e l of c a r e were a v a i l a b l e from the H.S.I  care u n i t p a t i e n t patient  separation  separation  days were s e p a r a t e d from  days and w i l l be reviewed l a t e r i n  report.  o f Care  Medical/Surgical  Patient S e p a r a t i o n Days 408,037  Allocated  Dollars  Daily  Cost  $26,627,016  $ 65.26  Paediatrics  55,486*  3,617,041  65. 19  Obstetrics  26,977  4,233,110  156. 92  Rehabilitation  13,370  540,477  40. 42  Extended  98,795  2,777,978  28..12  Source:  (Chronic)  A l l d a t a d e f i n i n g p a t i e n t s e p a r a t i o n days and beds s e t up f o r each l e v e l of c a r e come from 1975 A n n u a l R e t u r n o f H o s p i t a l - Form H.S.I f o r Vancouver G e n e r a l H o s p i t a l .  Occupancy of P a e d i a t r i c beds (167 beds set-up) appears to be h i g h , but d a t a r e f l e c t s f i g u r e s used by H o s p i t a l i n 1975 H.S.I form.  -  62  -  Emergency The d e t e r m i n a t i o n of a u n i t v a l u e f o r emergency  s e r v i c e s needed a  weight f a c t o r t h a t r e f l e c t e d the s e v e r i t y of t h e p a t i e n t ' s i n j u r y . The t r a d i t i o n a l c l a s s i f i c a t i o n system used i n t h i s department i s t r i - l e v e l , i.e.,  emergent,  i n the h e a l t h  u r g e n t and non-urgent.  Because of the department's r o l e  d e l i v e r y network, a s i g n i f i c a n t amount of s t a f f  and equipment r e s o u r c e s i s o r i e n t e d i n f r e q u e n t l y compared  to t h e emergent  skills  p a t i e n t , but used  to the use of the department by non-urgent patients';  In 1975, V.G.H. emergency  department s t a f f was  a l l o c a t e d i n the  f o l l o w i n g manner:^ 0  50% of s t a f f  •  27.9% of s t a f f  •  22.1% t o non-urgent s t a t i o n s  t o emergent  stations;  t o u r g e n t s t a t i o n s ; and  When t h e t o t a l 67,690 p a t i e n t v i s i t s were c l a s s i f i e d ,  only  emergent and 7,785 were u r g e n t ; the r e m a i n i n g p a t i e n t s were  4,330 were classified  as non-urgent.  Following  the same l o g i c used f o r o t h e r V.G.H. departments i n d e v e l o p i n g  unit costs, resources  emergent p a t i e n t s  s h o u l d have consumed 50% of department  ($2,475,151.80 from T a b l e D) as 50% of s t a f f were a s s i g n e d  to emergent  stations.  would be $285.80.  T h e r e f o r e a u n i t c o s t f o r the 4,330 p a t i e n t s  Urgent p a t i e n t s  totalling  C o n v e r s a t i o n s w i t h Head Nurse - Emergency  7,785 would use 27.9% of  Department  - 63  resources  -  or have a u n i t c o s t of $88.70.  Non-urgent p a t i e n t s would  have a u n i t c o s t of $9.85.  While t h i s p r o c e s s produced a u n i t d o l l a r v a l u e ,  i t is  questionable  whether i t r e f l e c t e d the a c t u a l use  of the department by  in  example, the  each of these t h r e e  levels.  For  the  s t a f f assigned  cannot p o s s i b l y spend a l l t h e i r time on emergent p a t i e n t s . time must be using  spent on  resources  study, i t was  of the  general  impossible  Without a "time and  F i n a l l y , the p a t i e n t m e d i c a l r e c o r d does not  classify  u r g e n t or non-urgent at the  arrival  ment, t h e r e f o r e  the weight f a c t o r was  of no v a l u e  their  patients  to f u r t h e r r e f i n e t h i s c l a s s i f i c a t i o n  time of h i s / h e r  to emergent  Some of  r o u t i n e or t r e a t i n g non-urgent  emergent w o r k s t a t i o n s .  patients  motion"  system.  the p a t i e n t as emergent, to the emergency d e p a r t -  to t h i s  study.  Other  methods o f w e i g h t i n g the demands of p a t i e n t s on the department's r e s o u r c e s , such as  time spent i n department, were e q u a l l y of l i t t l e  G i v e n t h a t a l l a n c i l l a r y and  diagnostic  radiology,  time, used by  laboratory  and  gency department w i l l be the p a t i e n t  OR  identified  emergency department.  in  services,  In 1975  assigned  an a p p r o p r i a t e  cost assigned i t was  to a l l p a t i e n t s u s i n g  the p a t i e n t  f o r an emergency v i s i t  emerto  felt  the  l o a d i n t h i s department  the a l l o c a t e d budget from T a b l e D was  an average v a l u e  specifically  the p a t i e n t w h i l e i n the  through the d i a g n o s t i c department/cost c e n t r e ,  t h a t an average cost, c o u l d be  67,690 and  and  t e s t s and  value.  was  $2,475,151.80, r e s u l t i n g  of $38.60.  - 64 -  T h i s approach i m p l i e s and  that  the same b a s i c r e s o u r c e s  low s e v e r i t y p a t i e n t s u s i n g  t h i s department.  were a l l o c a t e d f o r Because the emergency  needs o f MVA v i c t i m s c o u l d n o t be r e t r o s p e c t i v e l y c a t e g o r i z e d , not  lost  increased  i n using  a department average.  high  The non-urgent p a t i e n t  from $9.85 t o $38.60 f o r a d i f f e r e n c e o f $28.75.  a l l was cost  The emergent  p a t i e n t s u n i t c o s t d e c r e a s e d from $285.80 t o $38.60 f o r a d i f f e r e n c e o f $247.20.  T h e r e f o r e , the r e g r e s s i o n e q u a t i o n i n Chapter TV of t h i s t h e s i s ,  which analyses on  the r e l a t i o n s h i p o f c o s t w i t h s e v e r i t y i s r e s t r i c t e d ,  the conservative  side.  erring  I f a s u i t a b l e measure was made a v a i l a b l e t o  i d e n t i f y emergent, u r g e n t , and non-urgent p a t i e n t s w e i g h t e d u n i t c o s t , then the r e g r e s s i o n  and an a p p r o p r i a t e .  e q u a t i o n would be made more  s e n s i t i v e than the r e s u l t s i n Chapter IV i n d i c a t e .  - 65 -  Operating  Room  Operating  room u n i t c o s t s were d e r i v e d by u s i n g  factor.  time as the w e i g h t i n g  P h y s i c i a n c o s t s on a f e e f o r s e r v i c e b a s i s were n o t i n c l u d e d  i n t h i s study.  Therefore,  only  those  costs of operating  s u i t e s a t Vancouver G e n e r a l H o s p i t a l were c o n s i d e r e d .  the s u r g i c a l  The use o f  o p e r a t i n g room f a c i l i t i e s was averaged f o r a l l p r o c e d u r e s performed a t the H o s p i t a l i n 1975.  I t i s p o s s i b l e t h a t the s h o r t term  operating  room p r o c e d u r e s may take more s e r v i c e s than t h e c o s t a l l o c a t e d to them by  the time o f t h e o p e r a t i o n .  c o u l d be more s e v e r e  On the o t h e r hand, l o n g e r  term  than s h o r t term o p e r a t i o n s , and thus on the  average, use more s e r v i c e s than a l l o c a t e d by the time f a c t o r . major c o s t component i s s t a f f comparison a c r o s s  cases  cases.  p r e p a r a t i o n and r e c o v e r y  cost.  Therefore,  The  time i s the o n l y  valid  The use o f s k i n - t o - s k i n time assumes t h a t time i s p r o p o r t i o n a l t o a c t u a l o p e r a t i n g  room  time.  I n Vancouver G e n e r a l  H o s p i t a l t h e r e a r e over 30 o p e r a t i n g rooms; the  assumption was made t h a t a l l o p e r a t i n g rooms a r e t h e same. p r o c e d u r a l drawback was t h a t Vancouver G e n e r a l a running  H o s p i t a l d i d not keep  t o t a l o f time t h a t i t s o p e r a t i n g rooms were i n u s e .  overcome t h i s , r e c o r d s were k e p t d u r i n g 4 one-week p e r i o d s 1975; year's  The one  To  during  the times were m u l t i p l i e d by 13 to get an i n d i c a t i o n o f t h e t o t a l time.  seasonal  The 4 one-week p e r i o d s were chosen t o i n c l u d e  effects, vacations  and s t a t u t o r y h o l i d a y s so t h a t t h e  - 66 -  estimated  u t i l i z a t i o n f i g u r e s f o r 1975 would be r e p r e s e n t a t i v e o f the  actual figures.  F l u c t u a t i o n s across  the f o u r t o t a l s i n the f o l l o w i n g  c h a r t were e x p e c t e d .  These f l u c t u a t i o n s r e i n f o r c e the need t o choose r e p r e s e n t a t i v e weeks o f the y e a r t h a t r e f l e c t  f a c t o r s which i n f l u e n c e u t i l i z a t i o n  s t a t u t o r y h o l i d a y s and t r a d i t i o n a l s t a f f v a c a t i o n week w i t h  the s t a t u t o r y h o l i d a y  the weeks r e p r e s e n t i n g that during  this  for operations.  fall  (i.e.,  time p e r i o d s ) .  The  (May 18-24) had t h e lowest use, w h i l e  and w i n t e r  had the h i g h e s t  use,  suggesting  time o f y e a r most s t a f f and p h y s i c i a n s were a v a i l a b l e The week  representing  summer had a low use, r e f l e c t -  i n g the c o n c e r n t h a t both s t a f f and p a t i e n t s would be on h o l i d a y s .  Operating  Room  W.C.T.U. W.P.O.R. H.P.U.B.R. C.P.O.R. CP.A.R. H.P.O.R. D.O.R. Total Grand T o t a l  Feb.9-15  May  18-24  Aug.10-16  Nov.16-22  3,229  1,937  1,434  3,757  818 2,038 12,919 873 11,231 2,788  766 1,540 9,492 700 8,850 1,672  608 1,675 10,940 657 9,558 1,903  694 2,044 12,186 721 12,624 2,204  33,896  24,957  26,775  34,230  119,858 min.  - 67 -  To account  f o r a f u l l y e a r , t h e four-week sample o f 119,858 minutes  was m u l t i p l i e d by 13 t o g e t a p r o j e c t i o n o f 1,558,154 minutes o f o p e r a t i n g room time f o r 1975. S i n c e t h e OR-PAR c o s t s from T a b l e B were $8,862,851.30, t h e c o s t o f OR-PAR time p e r minute o f s k i n - t o s k i n time i n t h e o p e r a t i n g room was $5.69.  T h i s v a l u e was m u l t i p l i e d  a c r o s s t h e s k i n - t o - s k i n time noted on t h e MVA p a t i e n t ' s o p e r a t i n g room form  i n his/her medical record.  Electroencephalography The EEG department o f f e r s s i x e l e c t r o e n c e p h a l o g r a p h i c p r o c e d u r e s . T h i s p r e s e n t e d a d i f f i c u l t y because the i n t e r n a l o p e r a t i o n o f t h i s department d i d not o f f e r a p r e d e t e r m i n e d  r a n k i n g o f these s i x d i f f e r e n t  procedures.  To c o u n t e r a c t t h i s ,  t h e f e e s c h e d u l e of t h e p r o v i n c i a l government was  used as a r a n k i n g mechanism o f the s i x ways of d e l i v e r i n g an e l e c t r o encephalogram.  The r e a d e r may o b j e c t t o t h i s method, as these  figures reflect  t h e time needed by the p h y s i c i a n t o i n t e r p r e t  But  since  25% — 3 0 % o f t h e department's budget i s f o r m e d i c a l  and f o l l o w i n g a d v i c e from s c h e d u l e was u s e d . be d e v e l o p e d  the t e s t . staff  t h e c h i e f p h y s i c i a n o f t h e department, t h e f e e  T h i s a l l o w e d one approach  t h a t ranked  dollar  f o r a w e i g h t i n g system t o  t h e component t e s t s o f t h i s department.  The  f o l l o w i n g i s the process f o r a r r i v i n g a t the u n i t value f o r the s i x procedures  o f t h e EEG department.  - 68 -  Rank Based on Procedure L  e  a  u  r  e  Regular EEG Electrocortiography Speech Recordings Sphenoid electrode Recordings  Fee Schedule  r> ^ Rate  45.32 113.30 99.92  2,864 2 2 14 j.t  106.00  Injections of C o r t i c a l stimulants ICL, VEL, EMOG  , Number  127.12 66.50  8 8 79 7Q 2,969  Share of Department's Resources Resources resources Dollars D on^r-o %v  Share of i Total Total * . . Budget  ?m,/?o.mi $129,796.48 226.60 199.84  y4.07 94.07 0.16 0.16 0.14 0.14  252,863.54 252,863.54 430.09 430.09 376.33 376.33  88.29 215.05 188.17  i,4o4.uu 1,484.00  1.08 1.08  2,903.08 2,903.08  207.36  1,016.96 1,016.96 5,253.50 *  .74 .74 3.81 * °-  1,989.15 1,989.15 10,241.42  248.64 129.64  T n r n  .  Average . J= Unit Cost ,  T  With s u f f i c i e n t manpower and time, the average drain on the EEG department f o r each of the above procedures could be determined and ranked proportionately. not f e a s i b l e f o r t h i s study.  This was  There seems to be 2:1 r a t i o between average unit cost  and fee schedule cost (the same concerns are applicable f o r radiology - seen l a t e r in this section of the r e p o r t ) .  It i s u n l i k e l y that the government fee schedule  was developed so that physician costs would roughly equal a l l other departmental costs.  Since 96% of a l l tests of t h i s service were regular EEG and since those MVA  included  i n this analysis received only regular EEG, another methodology f o r determining unit cost f o r t h i s service would be to divide the cost ($268,803.60) by t o t a l tests (2,969) to get an average cost per test of $90.54. change  Using a weight factor did not  the unit cost s i g n i f i c a n t l y f o r this department i n context  of the demand  placed on t h i s department by MVA victims.  Intensive Care Unit The ICU department offered a rather simple process f o r determining i t s u n i t cost. The medical records department was able to determine that the t o t a l patient load in the ICU i n 1975 was 2,949 patient days.  Therefore, with the t o t a l yearly cost  of $851,053 from Table D, the unit cost was $288.60 per day.  - 69  -  Electrocardiography The  ECG  department p r o v i d e d  the o n l y o t h e r pacemakers.  s e r v i c e o f f e r e d was  The  minimal  Therefore,  services in  1975;  a telephone s e r v i c e f o r t e s t i n g  l a t t e r s e r v i c e was  the department was month).  p r i m a r i l y r e g u l a r ECG  ignored  because i t s d r a i n  (numbers t o t a l o n l y about 50  on  calls  w i t h the t o t a l c o s t of $686,294.10 and  number of t e s t s completed of 24,084, a u n i t c o s t per ECG  a  per total  would  be  $28.50.  Laboratory L a b o r a t o r y c o s t s were v e r y tory u n i t s entered  on  easily  the H.S.I  of t h i s department f o r 1975. all  d i v i s i o n s equalled  i d e n t i f i e d , given  form a c c u r a t e l y The  t h a t the  r e f l e c t e d the  29,020,595; the  step-down budget of  i s $7,467,466.10.producing a  unit  i n f e c t i o n c o n t r o l , research  But  c o n t r o l p r o c e d u r e s were not  workload  t o t a l number of l a b o r a t o r y u n i t s  department, from T a b l e D, c o s t of $0,257.  labora-  removed from the  removed, the c o s t per u n i t would i n c r e a s e  total.  this  laboratory and  quality  I f they were  to $0.34 and  i n Chapter IV would have shown a m a r g i n a l i n c r e a s e  across  the r e s u l t  i n the  differ-  ence of step-down c o s t i n g methodology from the Per Diem c o s t i n g method.  Each p a t i e n t ' s r e c o r d was of  laboratory  reviewed to determine the type and  t e s t s performed; standard  number  l a b o r a t o r y u n i t s f o r each t e s t  - 70 -  have been determined which f a c i l i t a t e  t h e p r i c i n g o f each t e s t .  The  f o l l o w i n g examples o f major t e s t s f o r each o f t h e major d i v i s i o n s o f the l a b o r a t o r y i l l u s t r a t e  the degree o f s p e c i f i c i t y  i n the p r o c e s s of  c o s t i n g used f o r t h i s  department.  Laboratory Division  Test  T o t a l Lab Units  Chemistry  • glucose • sodium  2 2  $0,257 0.257  $ 0.51 0.51  Hematology  • CBC • differential  3 8  0.257 0.257  0.77 2.04  Blood Bank  • grouping e cross-match  9 13  0.257 0.257  2.30 3.34  Histology  • slide 10 • c y t o l o g y smear 3 • cytology screen (gyn) 5  0.257 0.257 0.257  2.57 0. 77 1.28  Isotopes  • •  10 12  0.257 0.257  2.57 3.08  Microbiology  • aerobic • gram  3 3  0.257 0.257  0.77 0.77  Immunology  • pregnancy • ANA  2 50  0.257 $0,257  0.51 $12.85  thyroxine folate  Unit  Price  Total Price Per T e s t  Radiology R a d i o l o g y o f f e r e d a l a r g e number o f t e s t s which were n o t c o n d u c i v e to g r o u p i n g .  Further,  t h e department d i d not use a u n i t  comparable t o t h a t used i n L a b o r a t o r y .  But the r a d i o l o g y  system department  d i d have a p r e d e t e r m i n e d f e e s c h e d u l e f o r the p h y s i c i a n s s i m i l a r t o  -  71  t h a t used i n the EEG department  -  t o determine u n i t  costs.  F o r the  o v e r 50 t e s t s , t o o g r e a t a number to l i s t h e r e , t h e same p r o c e s s was a p p l i e d to determine i n d i v i d u a l t e s t c o s t s as was used f o r t h e s i x t e s t s of the EEG department. t e s t s by MVA  The most f r e q u e n t l y used  radiological  v i c t i m s a r e p r e s e n t e d h e r e as examples o f the u n i t  cost  determination.  Rank Based Fee S c h e d u l e Rank  Procedure  Number  P e r c e n t a g e of Department's Resources  New  Rate  Chest  $12.24  24,496  20.30%  $ 23.95  Skull  18.47  6,390  6.87%  36.16  Bone E x t r e m i t i e s  12.24  27,842  19.83%  23.95  C e r v i c a l Spine  14.73  2,588  2.22%  28.59  V o i d i n g Cystogram  30.59  588  1.05%  60.05  T h i r t y p e r cent of t h i s department's budget i s a l l o c a t e d staff fees.  Without a d e t a i l e d study on the a l l o c a t i o n of  department r e s o u r c e s f o r each t e s t p r o v i d e d , i t was f e l t this  thesis,  to medical  that, f o r  the f e e s c h e d u l e was the most a p p r o p r i a t e method of  r a n k i n g the component t e s t s of t h i s department.  (See s e c t i o n on EEG).  The r a d i o l o g y f i l m i s c o s t e d by u s i n g the same d o l l a r v a l u e s t h a t the h o s p i t a l paid f o r i t s f i l m .  Each m e d i c a l r e c o r d shows the type and  number of r a d i o l o g i c a l f i l m used; the p r i c e l i s t  i s as f o l l o w s :  - 72 -  F i l e Type  Price  B  $0.18  C  0.25  D  0.37  E  0.47  F  0.72  G  0.37  Dental  0.31  Pharmacy The t o t a l drug c o s t s , as mentioned the  v a r i o u s s e r v i c e departments  nursing units.  e a r l i e r , were a l l o c a t e d a c r o s s  u s i n g drugs, e.g., ward s t o c k to  The drug c o s t a l l o c a t e d  to pharmacy r e p r e s e n t e d the  c o s t s of those drugs used i n c o m p l e t i n g p r e s c r i p t i o n s f o r p a t i e n t s . The t o t a l pharmacy c o s t s from T a b l e D were d i v i d e d i n t o drug c o s t s and non-drug  costs.  From the m e d i c a t i o n c h a r t i n the m e d i c a l r e c o r d s , a complete those drugs g i v e n t o the p a t i e n t s f o r p r e s c r i p t i o n s was With the p r i c e l i s t  l i s t of  determined.  f o r drugs i n 1975, and the number of doses f o r  each drug, a t o t a l d o l l a r v a l u e was determined f o r drug c o s t f o r each p a t i e n t .  T h e r e f o r e the a l l o c a t e d t o t a l c o s t from T a b l e D f o r  Pharmacy s h o u l d have drug c o s t s e p a r a t e d and n o t i n c l u d e d i n the f o l l o w i n g d e t e r m i n a t i o n of p r e s c r i p t i o n  costs.  - 73 -  Table D A l l o c a t e d  $1,910,505.40  C o s t f o r Pharmacy - Drug Cost = Pharmacy Production Cost -  To produce a u n i t c o s t costs)  $1,125,825.34  =  $784,680.10  f o r each p r e s c r i p t i o n  (not i n c l u d i n g  an assumption was made t h a t a l l p r e s c r i p t i o n s would  same amount o f time i n p r e p a r a t i o n . a t o t a l number o f p r e s c r i p t i o n s the u n i t c o s t f o r f i l l i n g includes  drug take the  With t h i s assumption, and w i t h  filled  a t V.G.H. i n 1975 of 154,098, unit  cost  overhead t o o p e r a t e the pharmacy and t h e c o n s u l t a t i o n  time  of department  p r e s c r i p t i o n s was $5.09.  This  p e r s o n n e l w i t h o t h e r h o s p i t a l and m e d i c a l s t a f f .  From the m e d i c a l r e c o r d s ,  the number of p r e s c r i p t i o n s  filled for  each p a t i e n t was determined; t h i s was done by the a s s i s t a n t of pharmacy a t Vancouver  director  General H o s p i t a l .  Physical Medicine P h y s i c a l m e d i c i n e department seen i n T a b l e D.  Even though  costs  a r e l a b o u r i n t e n s i v e , as can be  t h e r e i s a h i g h overhead due t o the  l a r g e square f o o t a g e used by t h i s department, the  patient  i s i n the department  reflects  s t a f f member i s w i t h t h a t p a t i e n t . costs  the amount o f time  the amount o f time a.:.'  T h e r e f o r e , the u n i t v a l u e f o r  f o r p h y s i c a l m e d i c i n e was determined on an h o u r l y  basis.  The  t o t a l time worked i n p h y s i c a l m e d i c i n e , as p r e s e n t e d on the H.S.2 return  form, was 180,758 h o u r s .  T h i s hour f i g u r e d i v i d e d  i n t o the  - 74  -  c o s t from T a b l e D of $1,771,243 g i v e s o f f e r e d by u n i t s by  cost f o r patient  the p h y s i c a l m e d i c i n e department were s u b m i t t e d on record  i n five-minute  minute segment i n 1975  Since there  i s no  cost  record  t h e r a p i s t s , i t was s u f f i c e f o r the therefore,  felt  segments.  Therefore,  occupational  that  The  s e r v i c e s department p r o v i d e d  victims. services  of  these departments.  time was  a fair  to  and  departments,  a u d i o l o g y t e s t and i n d i c a t o r of  per  the  unit  I n the s o c i a l s e r v i c e department, a  were seen between 12 and  6 minutes and  input  v i c t i m s ; however,  work u n i t time study completed on a sample o f 269 cases showed 35%  or no  from these two  d e c i d e d t h a t an average v a l u e per  study,  salaries.  Only a u d i o l o g y  to MVA  o c c u r r e n c e of i n p u t  hour of s o c i a l s e r v i c e time would be costs  speech  research  r e m a i n i n g d i r e c t p a t i e n t s e r v i c e s have l i t t l e to MVA  by  the assumption of average s a l a r y would  assumed t h a t a l l such s t a f f have e q u a l  because of the low  five-  to p a t i e n t s  t h e r a p i s t s , and  d e t e r m i n a t i o n of u n i t c o s t .  the h o s p i t a l c a r e g i v e n  each  each  .820.  to determine the s e r v i c e s  l e v e l of p h y s i o t h e r a p i s t s ,  i t was  services  the p h y s i c a l m e d i c i n e department of $9.80 per hour.. Time  patient's  The  the  maximum was  opened and  18 m i n u t e s .  45 minutes.  Also,  The 72.6%  closed  minimum of  the  4 cases were seen i n two  or l e s s c o n t a c t s .  The  medical record  q u i t e vague on d e l i n e a t i n g the scope of s o c i a l s e r v i c e v i s i t s  L e t t e r from R.J. Marcus, D i r e c t o r , S o c i a l S e r v i c e s Vancouver G e n e r a l H o s p i t a l , November 4, 1977.  was to  Department,  - 75  patients. each MVA  -  One-half hour of the s o c i a l worker's time was v i c t i m who  received  budget of t h i s department was the H.S.2  form was  c o s t of o n e - h a l f  audiology  s e r v i c e s from the department. $746,662, and  therefore  one  t e s t noted from the  The  t o t a l budget was  was  6,375.  The  departments of the H o s p i t a l t h a t d i d not  to say  have i n p u t  i n T a b l e D were not  t h a t i n some s p e c i f i c i n s t a n c e i n t o the  treatment of MVA  r a t e of $9.26.  costed  used and  the p a t i e n t ' s  cost.  The  total  f i n a l department to be  question  t o be  the number of t o t a l t e s t s  show i n the a n a l y s i s were r e n a l and  used i n t h i s study.  i n a h o s p i t a l should community.  The  considered  be  psychology. This i s  c o u l d be  education.  i s whether the  o n l y s a l a r i e s and  a l l i e d health students,  not  i t would occur r a r e l y .  A  per  a l l o c a t e d to  legitimate  c o s t of  education  charged to the h o s p i t a l ' s p a t i e n t s or to  c o s t i n c l u d e s not  f o r medical students,  treatment  was  of  these departments would  v i c t i m s , but  a c o s t per  r a i s e d at t h i s point  The  at $13.85.  I f n e c e s s a r y , the same p r o c e d u r e f o r i d e n t i f y i n g the u n i t c o s t department c o u l d be  total  t o t a l p a i d hours from  r e c o r d s was  v i c t i m s ' medical records  T h e i r c o s t s as l i s t e d not  202  $88,315 from T a b l e D and  MVA  The  $4.63.  The  the sample of 202  the  80,628, which g i v e s an h o u r l y  hour was  a l l o c a t e d to  the  r e l a t e d expenses  i . e . , radiology  and  - 76 -  laboratory  technicians;  i t also includes  programs o f the h o s p i t a l s t a f f . the d i r e c t c o s t o f p r o v i d i n g  care  the i n - s e r v i c e  Some c o n s i d e r  t h i s c o s t to be beyond  t o t h e patient"', b u t s i n c e i t i s a  component o f b o t h m e d i c a l t r a i n i n g and c o n t i n u i n g included  i n the costs  education,  i t was  of treatment.  E d u c a t i o n c o s t s were d i s t r i b u t e d a c r o s s same manner as g e n e r a l  education  administration  a l l p a t i e n t c a r e areas i n the  (see Table D).  Magraw R.W.,M.D., "How Trends i n M e d i c a l E d u c a t i o n a r e A f f e c t i n g M e d i c i n e and H o s p i t a l , " H o s p i t a l s , October 1, 1963.  -  IV. The  77  -  DATA ANALYSIS previous  chapter o u t l i n e d a step-down approach to d e t e r m i n i n g  c o s t o f each s e r v i c e of the H o s p i t a l used by p a t i e n t ' s r e c o r d was  reviewed by  u n i t s i n each p a t i e n t  care a r e a  the MVA  of the h o s p i t a l used by  l a b e l l e d Step-Down E p i s o d i c Cost.  days -  605,614 days and  the v i c t i m .  an e p i s o d i c c o s t was  f o r a n a l y s i s of the i n t e r a c t i o n between c o s t and  c u l a t e d per diem c o s t v a l u e d  Each  the author to determine the number of  When these component c o s t s were t o t a l l e d ,  was  victim.  severity.  A second c o s t was  at $129.75 ( c a l c u l a t e d u s i n g  episodic cost represented  For  r e f e r r e d to as Per  Two  the  based on a total  • Measure the  and  T h i s method of d e t e r m i n i n g  of s t a y of the p a t i e n t ' s v i s i t  the remainder of the a n a l y s i s , t h i s second c o s t Diem E p i s o d i c  objectives for this  cal-  patient  t r a d i t i o n a l approach of m u l t i p l y i n g  diem r a t e times l e n g t h  the h o s p i t a l .  cost  t o t a l budget d o l l a r s minus those d o l l a r c o s t s  Grandview N u r s i n g Home - $78,578,420).  per  available  This  e x c l u d e d from the step-down c a l c u l a t i o n , i . e . , employee meals  constant  the  an a in was  Cost.  t h e s i s were i d e n t i f i e d  i n Chapter I:  c o r r e l a t i o n between e p i s o d i c c o s t and  injury severity;  and • Determine i f the chosen Step-Down p a t i e n t s p e c i f i c resulted  i n a s i g n i f i c a n t d i f f e r e n c e from the  Episodic  Costing.  c o s t i n g methodology  t r a d i t i o n a l Per  Diem  -  A.  P e r Diem v e r s u s Step-Down  i.  Episodic  The  78  -  Costing  Costs  second o b j e c t i v e l i s t e d e a r l i e r was  reviewed f i r s t  as a b a s i s f o r  b e t t e r u n d e r s t a n d i n g of the r e s u l t s o f the c o r r e l a t i o n a n a l y s i s . paired for  t-test,  comparing the Step-Down and Per Diem E p i s o d i c  each of the 202  p a t i e n t s i n the sample p o p u l a t i o n ,  t e s t used to d e t e r m i n e i f t h e r e was the two  was  A  Costs  the  first  a s i g n i f i c a n t d i f f e r e n c e between  cost methodologies.  TABLE E Paired t-Test E p i s o d i c Costs  Standard Deviation  Standard Error  $1,984.15  $2,989.22  $210.32  1,936.10  2,692.86  189.47  48.06  1,383.73  97.36  Mean P e r Diem E p i s o d i c Cost Step-Down E p i s o d i c C o s t Difference  With 201 was  degrees o f freedom, i t was  not  0.49  p o s s i b l e to suggest t h a t  a s i g n i f i c a n t d i f f e r e n c e between these two  d e v i a t i o n of the d i f f e r e n c e was  t-Value  too g r e a t  groups.  The  there  standard  compared to the mean of  the  difference.  It  was  concluded that  the t - t e s t was  r a n g e of p a t i e n t s i n t h i s  sample  weakened because of the wide  which a f f e c t e d the homogeneity n e c e s -  sary f o r a t - t e s t , r e s u l t i n g i n t h i s l a r g e standard  d e v i a t i o n of  the  - 79  difference. severity  -  P a t i e n t s of a l l ages and,  l e v e l s , were i n c l u d e d  more i m p o r t a n t l y ,  i n t h e s e 202  approaches were attempted t o c o u n t e r a c t  MVA  of a l l  victims.  Two  different  the i n f l u e n c e of the wide  range i n s e v e r i t y : • g r o u p i n g p a t i e n t s by • grouping p a t i e n t s Low  s e v e r i t y was  9 or l e s s . the v a l u e and  i n t o low,  medium, and  i d e n t i f i e d f o r any  T h i s group i n c l u d e d  and high  I.S.S. s c o r e  p a t i e n t w i t h an  those p a t i e n t s who  categories.  I.S.S. v a l u e had  one  top  three  injury sites.  life-threatening.  In t h i s case, the  H i g h s e v e r i t y was  of  i n j u r y of  3 i n the A.I.S., or m u l t i p l e i n j u r i e s w i t h a v a l u e  1 f o r the  were not  t h e i r A.I.S. s c o r e ;  of 2,  2  injuries  identified  f o r those  p a t i e n t s w i t h a s i n g l e l i f e - t h r e a t e n i n g i n j u r y , i . e . , A.I.S. v a l u e 5,  or a combination of i n j u r i e s  t h a t gave a comparable I.S.S.  t o t h a t of a s i n g l e l i f e - t h r e a t e n i n g i n j u r y . p a t i e n t s w i t h an I.S.S. s c a l e of g r e a t e r  and  Medium s e v e r i t y  between and  including  was 10  24.  Grouping p a t i e n t s by t h i s score  t h e i r A.I.S. s c o r e was  c o u l d e a s i l y be  felt  to be  q u a n t i f i e d without accessing  T h i s would be a c c o m p l i s h e d by u s i n g  of v a l u e , patient  the mapping t e c h n i q u e  e a r l i e r , which t r a n s l a t e s the p a t i e n t ' s I.C.D.-9 d i s c h a r g e following table and  score  T h i s group i n c l u d e d a l l  than 24.  i d e n t i f i e d as p a t i e n t s h a v i n g I.S.S. s c o r e s  of  (Table  c o s t , b o t h Per  measures on one  records.  explained code.  F) d i s p l a y s the r e s u l t s of a t w o - f a c t o r  Diem and  The  (A.I.S.  Step-Down) ANOVA t e s t , w i t h r e p e a t e d  factor (cost).  as  - 80 -  As  can be seen i n T a b l e F, the v e r y  low v a l u e , 0.0049, f o r the p r o b a b i l i t y  t h a t two c o s t i n g methodologies a r e s i m i l a r , was s u f f i c i e n t i n d i c a t e a d i f f e r e n c e between t h e c o s t i n g  T h i s same t e s t , a t w o - f a c t o r measures on o n e - f a c t o r  evidence to  methodologies.  (I.S.S. and c o s t ) ANOVA w i t h  repeated  ( c o s t ) , was performed on t h e two c o s t i n g  m e t h o d o l o g i e s h o l d i n g t h e t h r e e c a t e g o r i e s o f I.S.S., i . e . , low, medium and h i g h as t h e independent v a r i a b l e . r e s u l t s of t h i s t e s t .  T a b l e G d i s p l a y s the  As w i t h t h e t e s t u s i n g t h e components o f A.I.S.,  the r e s u l t s o f t h i s t w o - f a c t o r ANOVA t e s t , p=0.118, i n d i c a t e d t h a t t h e r e was s i g n i f i c a n t d i f f e r e n c e between t h e c o s t i n g  The  methodologies.  r e s u l t s o f t h e s e two ANOVA t e s t s as d i s p l a y e d i n T a b l e s F and G  suggested  t h a t t h e r e was a s i g n i f i c a n t d i f f e r e n c e between t h e two  c o s t i n g m e t h o d o l o g i e s f o r e p i s o d i c c o s t s when t h e independent v a r i a b l e of s e v e r i t y was c a t e g o r i z e d i n t o component c e l l s . ability  o f t h e two methodologies p r o d u c i n g  I n f a c t , t h e prob-  s i m i l a r c o s t s was s m a l l e r  when s e v e r i t y was c a t e g o r i z e d by A.I.S. g r o u p i n g s .  But f o r each t e s t  the s t a n d a r d d e v i a t i o n s of t h e dependent v a r i a b l e s , i . e . , Per Diem and Step-Down e p i s o d i c c o s t s , were v e r y h i g h f o r most o f t h e c e l l s of both  A.I.S. and I.S.S. when  compared  s t a n d a r d d e v i a t i o n c o u l d be reduced, validity  o f these  tests.  t o the c e l l  mean.  I f the  t h e r e c o u l d be an i n c r e a s e i n the  - 81 -  TABLE F .Two-Factor ANOVA w i t h Repeated Measures, E p i s o d i c Cost and A.I.S.  A.I.S. Values  P e r Diem Episodic Cost  Mean Standard Deviation Count  Step-Down Episodic Cost  Mean S tandard Deviation Count  1 557.4  2 807.6  3 2632. 6  4 2252.9  5 3875. 2  452.1  872.9  3512. 8  4078.5  3239. 2  11  15  49  536.4  868.2  2197. 7  2016.9  6140. 6  254.0  1479.8  2516. 5  2896.2  4301. 7  11  15  2134.9  5007. 9  100  49  27 546.9  Marginal  100  27  2415. 2  837.9  Analysis  202 1936.1  202 1960.1  of V a r i a n c e  Across Severity  (A.I.S.)  F^  d  f  Across Episodic  Cost  F^  d  f  I n t e r a c t i o n Term  Marginal 1984.1  ^ 1  = 10.84 =  ¥ (d.f.4,197)  8.10 = 16.42  p = 0.000 p = 0.0049 p = 0.000 F  - 82 -  TABLE G Two-Factor ANOVA w i t h Repeated Measures E p i s o d i c Cost and X.S,S.  I.S.S. C e l l s Low  Severity  High  Severity  2417.8  4442.4  2331.3  4686.8  129  52  21  1223.1  2140.8  5809.6  1  1679.4  4678.9  52  21  2279.3  5126.0  Mean Standard Deviation Count  1409.1  Per Diem Episodic Cost  Total Episodic Cost  Mean Standard Deviation Count  9  6  2  <  5  129 1316.1  Margina1  Medium S e v e r i t y  Marginal 1984.1  202 1936.1  202 1960.1  A n a l y s i s of Variance Across Severity  (I.S.S.)  Across Episodic  Cost  I n t e r a c t i o n Term  F  (d.f.2,199)  F  (d.f.1,199)  F  (d.f.2,199)  = 21.24  p = 0.000  =  p = 0.0118  6.46  =13.93  p = 0.000  -  The  o n l y way  83  -  to r e d u c e the s t a n d a r d  d e v i a t i o n was  to lower the range of  the d i f f e r e n c e between the Per Diem methodology of c o s t i n g and Step-Down methodology of c o s t i n g .  I t was  felt  the  t h a t the measure f o r  average d a i l y c o s t f o r each of these c o s t m e t h o d o l o g i e s would be appropriate  the  v a r i a b l e t o reduce the range of the d i f f e r e n c e v a r i a b l e  thus r e d u c e the s t a n d a r d  Daily  the  and  deviation.  Cost  I n the e p i s o d i c c o s t methodology, the l e n g t h of s t a y patient's v i s i t  to the h o s p i t a l was  (L.O.S.) of  an u n c o n t r o l l e d v a r i a b l e .  the Two  d i f f e r e n t p a t i e n t s , h a v i n g a p p r o x i m a t e l y the same Step-Down e p i s o d i c c o s t , c o u l d have had not  s i g n i f i c a n t l y d i f f e r e n t lengths  the c a s e f o r P e r Diem e p i s o d i c c o s t , as  d i r e c t m u l t i p l e of L.O.S. and the  v a r i e d as  i n f l u e n c e of L.O.S. as a way  r e p e a t e d measures were run, Of but  using  c o s t s was  t - t e s t c o u l d be  the s t a n d a r d  two-factor  ANOVA  To  was a  eliminate  d e v i a t i o n of test.with  the d a i l y c o s t of each methodology.  c o u r s e , t h e d a i l y c o s t of the Per a paired  This  t h i s e p i s o d i c c o s t was  the L.O.S. v a r i e d .  of r e d u c i n g  the c o s t v a r i a b l e , the p a i r e d t - t e s t and  of s t a y .  used, as  Diem methodology was  a  constant,  the d i f f e r e n c e between the  as randomly d i s t r i b u t e d as was  the Step-Down d a i l y  T a b l e H d i s p l a y s the r e s u l t s of t h i s p a i r e d  t-test.  two  cost.  - 84 -  TABLE H Paired t-Test D a i l y Cost  P e r Diem D a i l y  Cost  Step-Down D a i l y Difference  The  Cost  Mean  Standard Deviation  Standard Error  129.75  0  0  173.33  131.20  9.23  43.58  131.20  9.23  t - v a l u e shown i n T a b l e H suggested  t h a t t h e r e was a  t-Value  4.72  significant  d i f f e r e n c e between the two d a i l y r a t e s of each of the c o s t i n g methodologies.  What was more i m p o r t a n t was  the s t a n d a r d d e v i a t i o n i n t h i s  the r e l a t i v e l y s m a l l v a l u e of  t e s t compared w i t h the s t a n d a r d  a t i o n of the e p i s o d i c c o s t s d i s p l a y e d i n T a b l e E, page 78.  devi-  The p a i r e d  t - t e s t of the e p i s o d i c c o s t had a mean d i f f e r e n c e o f $48.06, w h i l e the mean d i f f e r e n c e between the two d a i l y r a t e s was $43.58. t h e s e means were c o m p a r a t i v e l y  close,  While  the s t a n d a r d d e v i a t i o n s were  remarkably d i f f e r e n t , w i t h the d a i l y c o s t s t a n d a r d d e v i a t i o n ($131.20) being one-tenth  of the s t a n d a r d d e v i a t i o n of the e p i s o d i c c o s t ($1383.73).  T w o - f a c t o r ANOVA t e s t s , w i t h r e p e a t e d measures f o r the d a i l y c o s t , p r o duced h i g h F v a l u e s of 35.46, p=0.00, when s e v e r i t y was measured i n t h e three groupings  o f I.S.S. (see T a b l e K) and 30.33, p=0.00, when s e v e r i t y  was c a t e g o r i z e d by A.I.S. (see T a b l e L ) .  Both i n d i c a t e d a s i g n i f i c a n t  d i f f e r e n c e i n the two m e t h o d o l o g i e s when d a i l y both  c o s t s were compared.  In  t a b l e s , T a b l e s K and L, t h e v a l u e s f o r the s e v e r i t y and the i n t e r -  a c t i o n terms were e x a c t l y the same, due t o t h e c o n s t a n t v a l u e of the d a i l y r a t e of the P e r Diem c o s t i n g methodology.  - 85 -  TABLE K Two-Factor ANOVA w i t h Repeated Measures, D a i l y Cost and I.S.S.  I.S.S. C e l l s Low  Severity  129.75  P e r Diem Daily Cost  Mean Standard Deviation Count  Total Daily Cost  Mean Standard Deviation Count  Medium S e v e r i t y  129.75  0.0  0.0  129  52  21  202  158.22  173.65  265.32  173.32  86.37  177.71  185.33  129  52  21  143.98  151.70  197.53  Analysis Across Severity  Interaction  129.75  129.75  Marginal  0.0  Marginal  Across D a i l y  High S e v e r i t y  (I.S.S.)  Cost Term  202 151.54  of Variance F  ( d . f .2,199)  F  ( d . f .1,199)  F  ( d . f .2,199)  =  6.34  P = 0.002  35.46  P = 0.000  6.34  P = 0.002  - 86 -  TABLE L Two-Factor ANOVA w i t h Repeated Measures, D a i l y Cost and A.I.S.  A.I.S. 2  1  Values 4  3  129.75  129.75  5  129.75  129.75  Marginal 129.75  129.75  P e r Diem Daily Cost  Mean Standard Deviation Count  174.81  162.48  158.72  220.76  268.67  173.33  Step-Down Daily Cost  Mean Standard Deviation Count  96.01  96.61  136.97  210.35  142.45  142.45  27  49  0.0  0.0  0.0  0.0  0.0  27  49  100  11  15  152.28  Marginal  Across D a i l y  (A.I.S.)  Cost  I n t e r a c t i o n Term  144.24  146.11  Analysis Across S e v e r i t y  100  11  202  202 .  15  175.25  199.21  151.54  of Variance F  ( d f 4 197)  2.83  p = 0.026  F, (d.f.1,197)  30.33  p = 0.000  2.83  p = 0.026  '(d.f .4,197)  - 87  FOOTNOTE TO TABLE K AND  -  TABLE L  * A comparison of T a b l e K w i t h T a b l e G or T a b l e L w i t h T a b l e F may suggest an apparent anomaly. T a b l e K and T a b l e L show t h a t w i t h i n each ISS o r AIS c a t e g o r y , the c o s t per p a t i e n t - d a y , c a l c u l a t e d by the step-down method and averaged a c r o s s a l l p a t i e n t s i n the c a t e g o r y , i s v e r y d i f f e r e n t from the h o s p i t a l - w i d e p e r diem. I n c a t e g o r y 4, T a b l e L, f o r example, the average step-down c o s t per p a t i e n t day i s $220.76, much above the h o s p i t a l - w i d e p e r diem of $129.75. On the o t h e r hand, the c o s t p e r e p i s o d e , c a l c u l a t e d by the step-down method, i s o n l y $2,016.97, compared w i t h the p e r diem based e p i s o d e c o s t of $2,252.93. Yet average l e n g t h of s t a y f o r b o t h groups i s the same, 17.36, because of c o u r s e they a r e the same p a t i e n t s , c o s t e d by two d i f f e r e n t m e t h o d o l o g i e s . The e x p l a n a t i o n i s a s t r o n g n e g a t i v e c o r r e l a t i o n between l e n g t h of s t a y and step-down based c o s t per p a t i e n t day. I f we d e s i g n a t e the f u l l y a l l o c a t e d c o s t of an e p i s o d e of c a r e f o r a s p e c i f i c p a t i e n t i , measured i n t h i s study, as E., the c o r r e s p o n d i n g l e n g t h of s t a y as D., and the h o s p i t a l - w i d e p e r diem as P, then the average c o s t per e p i s o d e f o r a p a r t i c u l a r group of n p a t i e n t s , c a l c u l a t e d by the step-down method, i s E^ = — n We  £ E. . I  , but by  the per diem method i s E  P  1=1  can c a l c u l a t e P. = E. f i  i  D.  as the c o s t per day,  V .  T  1=1  d e r i v e d by „  true i n general that f  D = E  g .  -s 1 E =— n  „  s .2 P. , . , l i=l  i s $3,832.39,  a t $2,016.97. , we can w r i t e : 1 =— n  n  y E. . . i i=l  s s ED..p. , and d e f i n i n g d. and p. as the amount by . T l * i l * i i=l  n  &  J  g  which the v a l u e s of D.  and P. f o r p a t i e n t i d e v i a t e from I l  of  n  Indeed, i n  T a b l e L, ISS group 4, IT* = 220.76, "5 = 17.36, t h e i r p r o d u c t S  PD.  the s t e p i  —s 1 can then c a l c u l a t e P = — n  g  f a r above E Factoring E  D. =  . x  i  down method, f o r each p a t i e n t i , and  b u t i t w i l l not be  = — P n .  the mean v a l u e s  the group,  I  s  £  =i  (D + d.) ( P  S  +  p*)  i=l , = n  n r i=l  = DP The m i d d l e  S  __ (DP  S  _ _ + Dp + P d . + d.pf) * i l i * i  + ± n i=l  S  d.p i s  1  terms become z e r o on summation over  the group as a whole.  -  88 -  FOOTNOTE TO TABLE K AND TABLE L (Continued)  s I f D. and P. a r e u n c o r r e l a t e d , 1 x n—>oo  then  n s V d.p.—>0 i*i ^  though f o r an a c t u a l s e t of o b s e r v a t i o n s  i n the l i m i t as on s m a l l n i t w i l l n o t .  g  In t h i s  case, though, D_^ and P^ t u r n out t o be s t r o n g l y  c o r r e l a t e d - some p a t i e n t s r e c e i v e v e r y others  negatively  i n t e n s i v e care a short  i n t h e same s e v e r i t y group may s u r v i v e a v e r y  long  time,  time a t lower  n T, d.p. i s l a r g e and n e g a t i v e . i=l T h i s o b s e r v a t i o n u n d e r s c o r e s t h e importance o f f o c u s s i n g on the o v e r a l l e p i s o d e o f c a r e , r a t h e r than t h e p e r diem c o s t s , i n making comparisons among p a t i e n t s w i t h d i f f e r e n t types o f problems. I t i n d i c a t e s , however, t h a t w h i l e s e v e r i t y measures e x p l a i n a s u b s t a n t i a l amount o f the v a r i a t i o n i n c o s t s , they do n o t by any means do t h e whole j o b , and c o n s i d e r a b l e v a r i a t i o n remains. A l l o f t h i s , however, i s masked by t r a d i t i o n a l l y f o c u s s i n g o n l y on h o s p i t a l - w i d e per diems and p a t i e n t l e n g t h s of s t a y . l e v e l s of care.  So  1  1  -  B.  Analysis  o f the I n f l u e n c e  The  primary o b j e c t i v e of t h i s  89 -  o f S e v e r i t y on the V a r i a t i o n i n Cost.  t h e s i s has been to i d e n t i f y t h e r e l a t i o n -  s h i p between c o s t and s e v e r i t y , and determine i f the Step-Down method of c o s t i n g was more r e s p o n s i v e to s e v e r i t y than was the Per Diem method of c o s t i n g . multiple  The f i r s t  regression  t a s k i n t h i s s e c t i o n o f d a t a a n a l y s i s was the  of episodic  c o s t s as the dependent v a r i a b l e , and  s e v e r i t y as t h e independent v a r i a b l e . of the e p i s o d i c  costs  costs  the r e g r e s s i o n  f o r Step-Down and P e r Diem methods where s e v e r i t y  was measured i n I.S.S. v a l u e s . episodic  Table M displays  Table N d i s p l a y s  the r e g r e s s i o n  f o r Step-Down and Per Diem methods where s e v e r i t y was  measured i n A.I.S.  scores.  TABLE M Regression Episodic  Costs With I.S.S.  Per Multiple R R  of the  2  Diem  Step-Down  0.335  0.507  0.112  0.257  0.108  0.253  2 Adjusted R F-value  25.22  69.02  - 90 -  TABLE N Regression  E p i s o d i c Costs W i t h A.I.S.  Per Diem Multiple R 2 A d j u s t e d R' F-value  Step-Down  0.317  0.462  0.101  0.213  0.096  0.209  22.39  54.25  F o r a l l r e g r e s s i o n s of P e r Diem and Step-Down e p i s o d i c c o s t s w i t h severity,  the F - v a l u e s  have an impact  showed s i g n i f i c a n c e .  T h e r e f o r e , s e v e r i t y does  on c o s t ; but the r e a l v a l u e of t h i s  t e s t was the q u a n t i -  f i c a t i o n of the e x p l a n a t o r y power t h a t s e v e r i t y had w i t h e p i s o d i c c o s t s . 2 The  adjusted R  v a l u e f o r Step-Down c o s t s and I.S.S., 0.253,  suggested  t h a t 25.3% of t h e v a r i a t i o n i n the Step-Down c o s t i n g methodology was attributable  t o , o r e x p l a i n e d by, c o - v a r i a n c e w i t h the s e v e r i t y as 2  measured by the I.S.S.  I n comparison, the a d j u s t e d R  value f o r the  r e g r e s s i o n of Per Diem e p i s o d i c c o s t s and I.S.S., 0.108, suggested 10.8%  of the v a r i a t i o n  only  i n P e r Diem e p i s o d i c c o s t s was a t t r i b u t a b l e to  c o - v a r i a n c e w i t h s e v e r i t y as measured by I.S.S.  Quite c l e a r l y , the  Step-Down method of c o s t i n g f o r e p i s o d i c c o s t s was more r e s p o n s i v e t o I.S.S. s e v e r i t y than was P e r Diem methodology when s e v e r i t y was measured by  - 91 -  F o r the two  r e g r e s s i o n s o f Per Diem and  Step-Down e p i s o d i c c o s t s w i t h  s e v e r i t y measured i n A.I.S. s c o r e s , the F - v a l u e s Again,  showed s i g n i f i c a n c e .  the v a l u e of these e q u a t i o n s was t h e i r a b i l i t y  to q u a n t i f y the 2  e x p l a n a t o r y power A.I.S. had w i t h e p i s o d i c c o s t s .  The  adjusted R  value  f o r Step-Down and A.I.S., 0.209, suggested t h a t 20.9% of the v a r i a t i o n i n t h i s c o s t methodology was a t t r i b u t a b l e t o , o r e x p l a i n e d by, c o - v a r i a n c e 2 w i t h A.I.S.  In comparison, the a d j u s t e d R  v a l u e f o r the r e g r e s s i o n o f  Per Diem e p i s o d i c c o s t s and A.I.S., 0.096, suggested the v a r i a t i o n i n Per Diem c o s t i n g was s e v e r i t y as measured by A.I.S.  t h a t o n l y 9.6%  a t t r i b u t a b l e to c o - v a r i a n c e  of  with  The A.I.S. s c o r e s d i d not seem to have  as h i g h an e x p l a n a t o r y power over the v a r i a t i o n of e p i s o d i c c o s t s as d i d the I.S.S. s c o r e s .  To  f u r t h e r analyze  t h i s r e l a t i o n s h i p between e p i s o d i c c o s t s  s e v e r i t y , r e g r e s s i o n a n a l y s i s was  performed on each of the Step-Down  c o s t components, as d e f i n e d i n Chapter measured by b o t h I.S.S. and A.I.S.  I I I of t h i s  a higher adjusted R  value.  2  t h e s i s , and  severity  T a b l e P p r e s e n t s the r e s u l t s  r e g r e s s i o n s of component c o s t s w i t h s e v e r i t y . had  and  Only  of  the l a b o r a t o r y c o s t  v a l u e than the Step-Down e p i s o d i c c o s t per  R  2  - 92 -  TABLE P R e g r e s s i o n of Component Costs With S e v e r i t y  Component  Cost  Severity I.S.S Adjusted R  Ward  Cost  2  F-Value  A.I.S 2 F-Value Adjusted R  0.207  53.5  0.169  41.8  O p e r a t i n g Room Cost  0.115  27.08  0.120  28.5  Radiology  0.149  36.15  0.086  20.0  Laboratory  0.307  89.85  0.255  69.7  Drugs/Pharmacy  0.039  9.09  0.031  7.4  Physiotherapy  0.058  13.43  0.046  10.6  T h e r e was l i t t l e component c o s t s ; its  daily rates.  value i n further exploring  the r e l a t i o n s h i p o f these  t h e f o c u s o f t h i s t h e s i s was on t h e e p i s o d i c  costs or  T a b l e P was p r e s e n t e d t o t h e r e a d e r t o i d e n t i f y t h a t  no one component c o n t r o l l e d t h e v a r i a n c e of Step-Down e p i s o d i c its  relationship with  severity.  costs i n  - 93 -  Test To  for Curvilinearity  ensure t h a t l i n e a r r e g r e s s i o n was the b e s t  approach f o r measuring  the r e l a t i o n s h i p between e p i s o d i c c o s t s and s e v e r i t y , the t e s t f o r c u r v i l i n e a r i t y was performed.  following  F o r t h i s a p p l i c a t i o n , the i n t e r -  v a l p r e d i c t o r v a r i a b l e w i t h d i s c r e e t v a l u e s was d i r e c t l y r e p r e s e n t e d by dummy v a r i a b l e s .  The s i g n i f i c a n c e o f the d e v i a t i o n from l i n e a r i t y was  t e s t e d by comparing the r e s u l t s o f l i n e a r r e g r e s s i o n w i t h the of dummy r e g r e s s i o n .  I n t h i s c a s e , the independent v a r i a b l e ,  s e v e r i t y measured by I.S.S. and A.I.S., was e n t e r e d i n t o the a n a l y s i s , using  dummy v a r i a b l e s f o r the components o f the  A.I.S. s e v e r i t y s c a l e s . (R F  2  The r e l e v a n t  w i t h Dummy V a r i a b l e s - R  2  =  (1-R  of  the  four  regression  I.S.S. and  F - t e s t was:  with o r i g i n a l :  variables)/(k)  w i t h Dummy V a r i a b l e s ) / ( N - k - 1 ) N = sample s i z e  For  results  k = number o f dummy v a r i a b l e s  tests for curvilinearity,  the r e l a t i o n s h i p o f b o t h e p i s o d i c  2 t h a t i s , comparing the R v a l u e  c o s t s w i t h I.S.S. and the  Revalue  2 of both e p i s o d i c  c o s t s w i t h A.I.S., t h e r e l e v a n t  r e s u l t i n g F - t e s t v a l u e are  displayed  R  v a l u e s and t h e  i n the f o l l o w i n g  table, TableQ .  TABLE Q Test  for Curvilinearity  2 R with Dummy V a r i a b l e s  2 R with Original Variables  F-Value  Degrees o f Freedom  Step-Down w i t h I.S.S. Step-Down w i t h A.I.S.  0.262 0.261  0.257 0.213  0.67 3.2  1 and 199 3 and 197  Per Per  0.100 0.122  0.112 0.101  1.33 1.18  1 and 199 3 and 197  Diem w i t h I.S.S. Diem w i t h A.I.S.  - 94  -  Only the F - v a l u e f o r Step-Down w i t h A.I.S. r e g r e s s i o n showed s i g n i f i c a n c e a t p=0.05, but  not  gories,  felt  i t was  i t y for regressions  a t p=0.01. C o n s i d e r i n g that  t h a t A.I.S. had  these r e s u l t s d i d not  of c o s t w i t h s e v e r i t y .  Influence  of Other Independent  Other v a r i a b l e s s p e c i f i c  one  v a r i a b l e which had  c o s t and  severity.  of e p i s o d i c c o s t .  severity.  significant  the  i n the  remaining  modify the r e l a t i o n s h i p  impact on  l e n g t h of s t a y  already  included  i n the  of the p a t i e n t , sex  an o p e r a t i o n ,  definition of  the s e v e r i t y of t h e i r based on  sex  and  to have been p o o r l y i n the p o p u l a t i o n , survive a high  s e v e r i t y , and  i n j u r y , measured by  groups.  But  represented on  died, influ-  t h a t were The  d i s p l a y s the d i s t r i b u t i o n of p a t i e n t s ' ages  s e v e r i t y , t h e r e was  or more age  the  whether the p a t i e n t  the a n a l y s i s o f the p a t i e n t s ' m e d i c a l r e c o r d s .  f o l l o w i n g graph, Graph 1,  was  the r e l a t i o n s h i p between  enced the r e l a t i o n s h i p between e p i s o d i c c o s t and  of one  r e j e c t 1: .xnear-  l o c a t i o n of the i n j u r y - were a l l f a c t o r s t h a t c o u l d have  measured d u r i n g  cate-  used.  seen e a r l i e r ,  f a c t o r s such as age  p a t i e n t , whether the p a t i e n t had and  As  T h i s v a r i a b l e was But  five  Variables  t o each p a t i e n t d i d  between e p i s o d i c c o s t and  sufficiently  Therefore,  a n a l y s i s , s t r a i g h t l i n e l i n e a r r e g r e s s i o n was  only  I.S.S.  With the sampling  p o t e n t i a l to have poor  o n l y the e l d e r l y w i t h h i g h i n the sample.  by  process  representation s e v e r i t y seem  P o s s i b l y they d i d n o t  exist  the assumption t h a t the e l d e r l y would not be a b l e  s e v e r i t y i n j u r y as w e l l as a younger p e r s o n .  to  - 95  In the f o l l o w i n g m u l t i p l e r e g r e s s i o n , dependent v a r i a b l e w h i l e the listed  -  e p i s o d i c c o s t remained as  independent v a r i a b l e i n c l u d e d  above as w e l l as s e v e r i t y .  T h i s e q u a t i o n was  the  those items  processed,  using  S.P.S.S. w i t h a s t e p - w i s e methodology t h a t a l l o w e d c o n t r o l over the of the  independent v a r i a b l e s , f o r b o t h Step-Down and  c o s t s f o r each of the s e v e r i t y s c a l e s . and  S f o r s e v e r i t y measured by  measured by  A.I.S.  The  I.S.S. and  Per  entry  Diem e p i s o d i c  r e s u l t s follow i n Tables  T a b l e s T and  U for severity  R  - 96 GRAPH 1 S e v e r i t y By Age  * #*  * »« * *  * *  o n  (NJ  * *  * Cvl  *  * «  *#  o  « *  o  1 •»  i. «  in  * * ** *  •J)  •  * o  i.  *  »*  1  in•  '0  * *  * *  *  • •  *  o  * * CVJ  « •  *  « ** * N * *  * #» * *  »  **  n .CJ<r  o O  O  10 o  I.S.S.  o  o n  N  *« * «  *  •  o N  •  ?l  * CJ* *  o  3 -• •  * «  o • •  ** * * *  o c  f>  CM CM •  o o  •  «* * *  ** * n* » CM  •  «  o  « *«  o  - 97 TABLE R Regression of Episodic Cost With M u l t i p l e Independent V a r i a b l e s and I.S.S, Per Diem Cost  Step-Down Cost  Severity Entered on F i r s t Step i n Dur. y Format: Adjusted R F-value  = 0.091 = 11.04  2  Adjusted R F-value  2  = 0.256 = 35.45  2  = 0.260 = 12.78  Age Entered on Second Step i n Dummy Format: Adjusted R F-value  = =  2  0.100 ' 4.71  Adjusted R F-value  Sex Entered on T h i r d Step i n Dummy Format: Adjusted R F-value  = =  2  4  0.095 0  2  Adjusted R = 0.256 F-value = 2  1  0  9  2  Operation not Performed Entered on Fourth Step i n Dummy Format: Adjusted R F-value  2  = 0.209 =7.65  Adjusted R F-value  2  = 0.370 = 15.77  Death as an Outcome Entered on F i f t h Step i n Dummy Format: 2 9 Adjusted R = 0.246 Adjusted R = °-43 F-value = 8.3 F-value = 18.13 Injury Location Entered on Sixth Step i n Dummy Format: 2 9 Adjusted R = 0.271 Adjusted R = 0.443 F-value = 6.34 F-value = 12.46 Severity 2nd order I n t e r a c t i v e Terms Entered on Seventh Step: Adjusted R F-value  2  = =  0.270 5.14  Adjusted R F-value  2  = 0.468 = 10.83  Age 2nd order I n t e r a c t i v e Terms Entered on Eighth Step: 2 9 Adjusted R = 0.272 Adjusted R = 0.477 F-value =4.59 F-value = 9.72  Sex, Operation and Death 2nd order I n t e r a c t i v e Terms Entered on Ninth S' Adjusted R F-value  2  = =  0.263 3.99  Adjusted R F-value  2  = 0.483 = -82 8  Injury Location 2nd order I n t e r a c t i o n Terms Entered on Tenth S t e p : Adjusted R F-value  2  = =  0.25 3.31  Adjusted R F-value  2  = 0.479 = 7.39  - 98 -  TABLE S C o - e f f i c i e n t s o f Independent V a r i a b l e s  and I.S.S.  Step-Down E p i s o d i c Cost and S e v e r i t y Measured by I.S.S,  VARIABLE  B  -5189.45 I.S.S. 0- 9 -5010.14 10-24 I.S.S. -2254.44 0-14 Age -1591.42 15-44 Age -728.03 45-64 Age 592.10 Sex (Female) O p e r a t i o n Not Performed -2025.32 13348.87 Death a s Outcome 1186.69 Head Injury 850.23 Face Injury 1802.68 Chest Injury Abdomen -377.21 Injury Extremities 1615.18 Injury Sex x S e v e r i t y -4.97 Operation x Severity 160.95 Death x S e v e r i t y -470.15 Age x S e v e r i t y 0.43 Age x Sex -1.04 Age x O p e r a t i o n -23.83 Age x Death -41.18 Sex x O p e r a t i o n -939.84 Sex x Death -3483.28 O p e r a t i o n x Death -3149.97 Severity x Location 0.000 Age x L o c a t i o n 0.000 Sex x L o c a t i o n 0.000 Operation x Location 0.000 Death x L o c a t i o n 0.000 Constant 7748.56  BETA  -0.92 -0.81 -0.26 -0.28 -0.09 o.io -0.37 0.90 0.19 0.08 0.19 -0.04 0.28 -0.01 0.39 -0.94 0.00 -0.00 -0.20 -0.10 -0.15 -0.12 -0.16 0.05 -0.02 -0.03 -0.24 -0 14  STD ERROR B  895.92 783.88 1108.12 962.27 992.63 968.52 794.58 6723.79 1389.34 1404.41 1449.66 1487.82 1361.37 43.60 47.72 147.15 0.86 15.18 15.26 44.79 709.55 2292.75 1905.01 0.00 0.00 0.00 0.00 0.00  F  33.55 40.85 4.13 2.73 0.53 0.37 6.49 3.94 0.73 0.36 1.54 0.06 1.40 0.01 11.37 10.20 0.00 0.00 2.43 0.84 1.75 2.30 2.73 0.38 0.07 0.26 2.11 0.79  - 99 -  TABLE S (Cont'd.)  11.  Per  Diem E p i s o d i c  VARIABLE I.S.S. 0- 9 I.S.S. 10-24 Age 0-14 Age 15-44 Age 45-64 Sex (Female) O p e r a t i o n Not Performed Death as Outcome I n j u r y - Head I n j u r y - Face I n j u r y - Chest I n j u r y - Abdomen Injury - Extremities Sex x S e v e r i t y Operation x Severity Death x S e v e r i t y Age x S e v e r i t y Age x Sex Age x O p e r a t i o n Age x Death Sex x O p e r a t i o n Sex x Death O p e r a t i o n x Death Severity x Location Age x L o c a t i o n Sex x L o c a t i o n Operation x Location Death x L o c a t i o n Constant  Cost and S e v e r i t y Measured by I.S.S,  B -3921.08 -3506.14 -1067.14 -399.51 420.30 119.83 -1612.52 5762.51 1800.42 1251.79 1935.37 1394.01 2942.66 -32.64 113.66 -283.70 -0.52 15.00 -27.27 -15.51 -598.82 -1445.36 -701.08 0.000 0.000 0.000 0.000 0.000 4704.74  BETA -0.63 -0.51 -0.11 -0.06 0.05 0.01 -0.26 0.35 0.26 0.11 0.18 0.14 0.46 -0.07 0.24 -0.51 -0.07 0.11 -0.20 -0.03 -0.08 -0.04 -0.03 0.0 -0.02 -0.02 -0.22 -0.08  STD ERROR B 1193.98 1044.67 1476.78 1282.41 1322.87 1290.74 1058.93 8960.72 1851.55 1871.64 1931.95 1982.80 1814.29 58.11 63.60 196.11 1.15 20.23 20.34 59.69 945.61 3055.52 2538.79 0.00 0.00 0.00 0.00 1094.66  10.78 11.26 0.52 0.09 0.10 0.00 2.31 0.41 0.94 0.44 1.00 0.49 2.63 0.31 3.19 2.09 0.20 0.55 1.79 0.06 0.40 0.22 0.07 0.00 0.06 0.09 1.31 0.18  -  The  results displayed  100  -  i n T a b l e s R and  c o s t w i t h s e v e r i t y measured by  S f o r the r e g r e s s i o n of  I.S.S., a r e s e l f - e x p l a n a t o r y .  independent v a r i a b l e s were i n t r o d u c e d s t e p s , but  only  episodic The  i n t o the e q u a t i o n i n t e n d i f f e r e n t  t h r e e of t h e s e produced m e a n i n g f u l changes i n  the  2 adjusted  R  value.  formed, and  These were s e v e r i t y , whether an o p e r a t i o n  death as an outcome.  Age,  sex,  was  i n j u r y l o c a t i o n , and  permost of  2 the second o r d e r  i n t e r a c t i o n had  little  impact on  the a d j u s t e d  The  F - v a l u e s i n T a b l e S showed t h a t one  age  group, t h a t b e i n g  age  group w i t h age  14,  and  being cost.  between 0 and  the abdomen, might have had But  some impact on  one  F-values,  between e p i s o d i c c o s t and  the  the v a r i a t i o n o f  i n d i c a t e d t h a t the age  body location-abdomen, d i d not  value.  episodic  those independent groups 0-14  and  15-44,  s i g n i f i c a n t l y a f f e c t the r e l a t i o n s h i p  severity.  Therefore,  the  independent v a r i a b l e s  included  i n the r e g r e s s i o n model to determine e p i s o d i c c o s t s were  severity  (measured by  and  first  body l o c a t i o n , t h a t  a subsequent r e g r e s s i o n performed w i t h o u t  v a r i a b l e s w i t h low and  valued  R  I . S . S . ) , o p e r a t i o n not  performed, death as outcome,  t h e i r i n t e r a c t i o n terms.  T a b l e s T and  U d i s p l a y the r e s u l t s of r e g r e s s i o n a n a l y s e s  of e p i s o d i c  costs  w i t h the same independent v a r i a b l e s as above, except f o r s e v e r i t y , which was  measured by A.I.S. s c o r e s .  The  adjusted  R  2  value  of Step-Down c o s t s 2  w i t h A.I.S. r e g r e s s i o n was  l a r g e r than the a d j u s t e d  and  ten steps.  A.I.S. f o r each of the  g r e s s i o n of Per  Diem e p i s o d i c c o s t and  The  R  value  of Per  f i n a l F - v a l u e , 2.63,  Diem  f o r the  the independent v a r i a b l e s ,  was  re-  101 TABLE T Regression o f E p i s o d i c Cost W i t h M u l t i p l e Independent V a r i a b l e s and A . I . S .  P e r Diem Cost S e v e r i t y E n t e r e d on F i r s t Adjusted R F-value  = 0.104 =6.85  2  Step-Down Cost  Step i n Dummy Format: Adjusted R F-value  2  = 0.246 = 17.42  Age  E n t e r e d on Second Step i n Dummy Format: 2 9 Adjusted R =0.114 Adjusted R = F-value = 4.22 F-value = Sex E n t e r e d on T h i r d Step Adjusted R F-value  2  = 0.109 = -?3 3  0.253 9.51  i n Dummy Format: Adjusted R = 0.249 F-value = 8.41 2  O p e r a t i o n Not Performed E n t e r e d on F o u r t h Step i n Dummy Format: Adjusted R F-value  2  = 0.206 =6.23  Adjusted R F-value  Death as an Outcome E n t e r e d on F i f t h Adjusted R F-value  2  = 0.227 = «35 6  Step  2  = 0.353 = 11.97  i n Dummy Format:  Adjusted R = 0.390 F-value = 12.67 2  Injury  L o c a t i o n E n t e r e d on S i x t h Step i n Dummy Format: 2 9 A d j u s t e d R = 0.240 Adjusted R = 0.399 F-value =4.96 F-value = 9.33 Severity  2nd o r d e r I n t e r a c t i v e Terms E n t e r e d on Seventh  Adjusted R F-value Age  = 0.226 =3.94  Adjusted R F-value  2  = =  2nd o r d e r I n t e r a c t i v e Terms E n t e r e d on E i g h t h  Adjusted R F-value Sex,  2  2  = 0.224 =3.53  Adjusted R F-value  2  = =  Step:  0.395 7.56 Step: 0.395 6.79  O p e r a t i o n and Death 2nd o r d e r I n t e r a c t i v e Terms E n t e r e d on N i n t h St  Adjusted R F-value  2  = 0- ? =3.15 2 1  Adjusted R F-value  2  = =  0.393 6.01  I n j u r y L o c a t i o n 2nd o r d e r I n t e r a c t i o n Terms E n t e r e d on Tenth Adjusted R F-value  2  =0.202 =2.63  Adjusted R F-value  2  = 0.388 =5.10  Step:  102 -  TABLE  U  C o - E f f i c i e n t s o f Independent V a r i a b l e s and A.I.S,  i.  Step-Down E p i s o d i c Cost and S e v e r i t y Measured by A.I.S.  VARIABLE  B  BETA  A.I.S. - 1 A.I.S. - 2 A.I.S. - 3 A.I.S. - 4 Age 0-14 Age 15-44 Age 45-64  -3352.62 -5371.66 -4690.26 -3687.42 -1177.91 -546.35 -23.96  -0.42 -0.85 -0.87 -0.31 -0.13 -0.09 -0.00  Sex (Female) Operation Net Performed Death as Outcome I n j u r y - Head I n j u r y - Face I n j u r y - Chest I n j u r y - Abdomen Injury - Extremities Sex x S e v e r i t y Operation x Severity Death x S e v e r i t y Age x S e v e r i t y Age x Sex Age x O p e r a t i o n Age x Death Sex x O p e r a t i o n Sex x Death O p e r a t i o n x Death Severity x Location Age x L o c a t i o n Sex x L o c a t i o n Operation x Location Death x L o c a t i o n  701.98 -3085.22 -20607.62 3784.85 3571.03 5182.43 3091.55 4457.86 -90.05 833.85 2928.78 3.51 -2.51 -23.24 -40.10 -658.86 -1035.12 -711.06 0.000 0.000 0.000 0.000 0.000 3537.63  0.12 -0.56 -1.40 0.62 0.35 0.54 0.35 0.77 -0.04 0.42 0.88 0.08 -0.02 -0.19 -0.10 -0.10 -0.03 -0.03 -0.22 -0.29 -0.21 -0.27 0.41  Constant  STD ERROR B 2022.67 1333.57 987.04 1154.10 1307.09 1074.47 1086.40 1548.03 1900.13 46021.24 2576.65 2680.87 2858.16 2784.23 2650.22 417.79 609.44 8617.24 6.89 16. 70 16.84 47.53 789.33 1998.56 2238.12 0.00 0.00 0.00 0.00 3049.30  F 2.74 16.22 22.58 10.20 0.81 0.25 0.00 0.20 2.63 0.20 2.15 1.77 3.28 1.23 2.82 0.04 1.87 0.11 0.26 0.02 1.90 0.71 0.69 0.26 0.10 0.88 0.07 0.06 1.73 0.46  -103 -  TABLE U  11.  (Cont'd.)  Per Diem E p i s o d i c Cost and S e v e r i t y Measured by A.I.S  VARIABLE  B  BETA  A.I.S. - 1 A.I.S. - 2 A.I.S. - 3 A.I.S. - 4 Age 0-14 Age 15-44 Age 45-64  -2769.73 -3870.70 -1958.10 -856.62 -211.98 518.31 841.32  -0.31 -0.55 -0.32 -0.06 -0.02 0.08 0.10  Sex (Female) Operation Not Performed Death as Outcome I n j u r y - Head I n j u r y - Face I n j u r y - Chest I n j u r y - Abdomen Injury - Extremities Sex x S e v e r i t y Operation x Severity Death x S e v e r i t y Age x S e v e r i t y Age x Sex Age x O p e r a t i o n Age x Death Sex x O p e r a t i o n Sex x Death O p e r a t i o n x Death Severity x Location Age x L o c a t i o n Sex x L o c a t i o n Operation x Location Death x L o c a t i o n Constant  855.34 122.55 -26080.24 3202.20 2752.95 4348.06 3355.93 4485.78 -286.20 -305.53 4327.63 1.95 9.85 -23.93 -23.10 -670.26 250.54 2107.93 0.000 0.000 0.000 0.000 0.000 708.76  0.13 0.02 -1.59 0.47 0.24 0.41 0.34 0.70 -0.13 -0.13 1.18 0.04 0.07 -0.18 -0.05 -0.09 -0.00 -0.09 -0.27 -0.03 -0.01 -0.10 0.24  STD ERROR B 2563.71 1690.29 1251.06 1462.81 1656.72 1361.88 1377.00 1962.11 2408.39 58331.38 3265.88 3397.97 3622.68 3528.97 3359.13 529.55 772.45 10922.25 8.73 21.17 21.35 60.25 1000.47 2533.15 2836.79 0.00 0.00 0.00 0.00 3864.95  F 1.16 5.24 2.45 0.34 0.01 0.14 0.37 0.19 0.00 0.20 0.96 0.65 1.44 0.90 1.78 0.29 0.15 0.15 0.05 0.21 1.25 0.14 0.44 0.01 0.55 1.01 0.08 0.02 0.19 0.12  -  104  -  c l o s e t o the t h r e s h o l d measure of s i g n i f i c a n c e f o r t h i s (degrees of freedom 31 and  170  F = 1.46  at p = 0.05).  F-value, From T a b l e U, i t  can be noted t h a t f o r t h i s r e g r e s s i o n s e v e r i t y , o p e r a t i o n body l o c a t i o n s and cant  F-values.  significant  s e v e r a l of t h e i r i n t e r a c t i o n terms d i s p l a y e d  signifi-  A subsequent r e g r e s s i o n , w i t h o u t those independent  v a r i a b l e s w i t h low was  performed,  F-values,  i n d i c a t e d that only  i n the r e g r e s s i o n of e p i s o d i c  measured by A.I.S.  scores.  the F - v a l u e f o r s e v e r i t y  costs, with s e v e r i t y  - 105  -  R e g r e s s i o n Model The  objective  of  t h i s t h e s i s has  impact of s e v e r i t y on s i o n of e p i s o d i c to be  a better  been to measure the  the measurement of e p i s o d i c  c o s t and  For  The  first  and  s e v e r i t y measured by  t h a t r e a s o n , the f o l l o w i n g  r e g r e s s i o n model was  action  the  I.S.S., o p e r a t i o n  displays  and  regres-  I.S.S. proved  than s e v e r i t y  regression  The  cost not  as  the  model  was  dependent v a r i a b l e  performed and  death  second model i n c l u d e d  death w i t h s e v e r i t y .  the r e s u l t s of  the  I.S.S.  b u i l t using  independent v a r i a b l e s .  terms of o p e r a t i o n  T a b l e V,  cost  of  In the  s e v e r i t y , s e v e r i t y measured by  d e v e l o p e d s o l e l y f o r s e v e r i t y measured by  outcome as  cost.  p r e d i c t o r o f v a r i a t i o n of e p i s o d i c  measured by A.I.S.  strength  those r e g r e s s i o n  The  as  the  following  inter-  table,  analyses.  For b o t h c o s t i n g m e t h o d o l o g i e s , the a d d i t i o n of i n t e r a c t i o n terms seemed to have had  l i t t l e e f f e c t on  independent v a r i a b l e s  the  adjusted R  d i d reduce the  2  value.  But  these  extra  l e v e l of s i g n i f i c a n c e as measured  by  2 the F-term.  The  minor d e c r e a s e i n the  adjusted R  v a l u e s compared w i t h  2 the  adjusted R  values displayed  fewer independent v a r i a b l e s e q u a t i o n i n m e t r i c form, not The  and  as an  Per  having introduced  f i r s t model are  Diem e p i s o d i c  outcome appeared to be  r e s u l t e d from h a v i n g  severity into  the  c a t e g o r i c a l form or dummy form.  r e s u l t i n g e q u a t i o n s f o r the  3 f o r Step-Down and  e a r l i e r i n T a b l e R,  an  cost,  displayed  respectively.  important v a r i a b l e as  i n Graphs 2  and  Having death  the e q u a t i o n  lines  -  106  -  f o r n o n - s u r v i v o r s were s u b s t a n t i a l l y removed from the o r i g i n a l line.  I n b o t h c o s t i n g m e t h o d o l o g i e s , when a p a t i e n t  v a l i d only  at h i g h  s e v e r i t y and  predicted  died,  who  survived.  The  impact of h a v i n g an o p e r a t i o n  was  o l o g y and  whether the p a t i e n t s u r v i v e d  increased  when the p a t i e n t had  the  same s e v e r i t y who  o r not  episodic  s e r v i c e s of  comparable e f f e c t i n i n c r e a s i n g  When the  t h a t i s , the o v e r a l l c o s t s  a Per  compared to the  R e g a r d l e s s o f whether  Diem method or by  costing a l l had  to the  two  e s p e c i a l l y evident  regression  equations  co-efficient variables.  i n the p v a l u e f o r death  Because the  i n the m e t r i c v i c t i m was  severity  form, not  i n dummy form, the r e a l s e v e r i t y measure o f i n t e r a c t i o n term.  The  the v a l u e of t h i s i n t e r a c t i o n term of two  '3' and  one  second  i n t e r a c t i o n term of "death x s e v e r i t y " used s e v e r i t y  used to c a l c u l a t e the  amples g i v e  as  f o r the Step-Down method where )B  changed from -$4,218.16 to +$1,125.73 from the f i r s t model to the model.  a  cost.  the most s i g n i f i c a n t change o c c u r r e d T h i s was  patient with  the p a t i e n t , h a v i n g an o p e r a t i o n  i n t e r a c t i o n terms were i n t r o d u c e d  outcome.  same s e v e r i t y  or d i e d ;  (the second model), t h e r e were minor changes i n the But  treatment  f o r each c o s t i n g method-  d i d not have an o p e r a t i o n .  the h o s p i t a l used by  was  consistent  an o p e r a t i o n ,  c o s t s were measured by  the model  a much lower c o s t of  compared w i t h the c o s t o f treatment of a p a t i e n t w i t h the  regression  with s e v e r i t y  '30.'  following  v i c t i m s , one  the  exwith  - 107 -  TABLE V C o - e f f i c i e n t s o f Independent V a r i a b l e s i n t h e R e g r e s s i o n Models  Per  Diem  Step-Down  F i r s t Model(Without I n t e r a c t i o n Terms) p Values - I.S.S. 0-9 - I.S.S. 10-24 - O p e r a t i o n Not Performed - Death as Outcome - Constant Multinle  R  -2921.58 -2284.87 -1970.11 -3599.51 5674.68 0.503 0.253 0.238  Adjusted R  16.72  F-Value  -4751.03 r4113.62 -1708.22 -4218.16 7139.33 0.665 0.442 0.431 39.06  Second Model(With I n t e r a c t i o n Terms) B Values - I.S.S. 0-9 - I.S.S. 10-24 - O p e r a t i o n Not Performed - Death as Outcome - Operation* x S e v e r i t y - Death x S e v e r i t y - Operation ' x Death - Constant 5  5  Multiple R R2 Adjusted R F-Value  O p e r a t i o n not performed.  -2664.81 -2495.20 -2777.87 - 431.65 88.43 - 155.13 432.35 5659.78 0.521 0.271 0.245 10.3  -4510.07 -4446.73 -2642.12 1125.73 110.29 - 210.54 -1151.60 7149.85 0.688 0.473 0.454 24.85  - 108 GRAPH 2  - Model 1  Step-Down C o s t s By O p e r a t i o n , Death and I•S.S.  SteD-Down E p i s o d i c  Costs  - 110  -  Value of I n t e r a c t i o n Term Death x S e v e r i t y  I n t e r a c t i o n Term  =  B x Death* x S e v e r i t y  f o r ISS = 3  = -210.54 x 1 x 3  f o r ISS = 3 0  = -210.54 x 1 x 30 = - $6,316.20  = - $  631.62  * Death was e n t e r e d i n t o r e g r e s s i o n e q u a t i o n i n dummy format v a l u e o f ' I ' i f death o c c u r r e d and '0' i f v i c t i m s u r v i v e d . A t any v a l u e of ISS over 6, B f o r death as outcome.  the i n t e r a c t i o n term c o u n t e r a c t s the  I f a low  more h o s p i t a l r e s o u r c e s would be survived.  Conversely,  severity victim dies, used than f o r low  positive  i t i s l o g i c a l that  severity patients  i f a high severity patient dies,  who  i t i s l o g i c a l that  fewer r e s o u r c e s a r e used f o r t h i s p a t i e n t than f o r a comparable p a t i e n t who  survived.  The  i n t e r a c t i o n term " o p e r a t i o n x s e v e r i t y " behaves i n a s i m i l a r manner.  As  d a t a support  this  argument.  s e v e r i t y i n c r e a s e s , the r e g r e s s i o n l i n e  "no this But  The  operations" veers  i n Graph 4 and  i n t o the " w i t h o p e r a t i o n " l i n e .  i n t e r a c t i o n term c o u n t e r a c t s  Graph 5 f o r  At h i g h  severity  the B v a l u e f o r ' o p e r a t i o n not  i n t h i s sample of h o s p i t a l i z e d MVA  p a t i e n t s w i t h a h i g h s e v e r i t y s c o r e who l e s s of whether they s u r v i v e d o r d i e d .  performed.'  v i c t i m s t h e r e were v i r t u a l l y  no  d i d not have an o p e r a t i o n r e g a r d -  - I l lGRAPH 4.  - Model 2  Step-Down C o s t s By O p e r a t i o n , Death, and I n t e r a c t i o n Terms  o o  • SI •e _  c  —  •  N  O  o "1 —  '33  •  M  **  m  •• Z*  o  •  »  •  iO  •Tl  • •SI c '  o  r.' »  c  c  . •»  Step-Down C o s t s  Severity  f •SI • o  Li  N  rja  N  —i  •  in  - 112 GRAPH  5  - Model 2  Per Diem C o s t s By O p e r a t i o n , Death, and I n t e r a c t i o n Terms  Severity  -  The  r e a l change w i t h the  decrease i n slope  113  -  i n t r o d u c t i o n of the  f o r p a t i e n t s who  died.  d i c t i v e power f o r those p a t i e n t s who whether or not  the p a t i e n t had  an  i n t e r a c t i o n terms was  With the  d i e d was  second model the  minimal, r e g a r d l e s s  same type of change, going from Model 1 t o Model 2, o c c u r r e d  Per  Diem Methodology f o r c o s t i n g f o r p a t i e n t s who  came n e g a t i v e ,  suggesting  i n f l u e n c e the  Results  measured by  d i e d , the  quite small  the  Based on  c o n c l u d e d t h a t Step-Down c o s t i n g was  t h a n was  slope  be-  decreases. thus d i d not  not  surpristhe  stay.  several  identi-  of whether c o s t  the assumption t h a t the the best  the  was  regression with  was  costing  measure o f c o s t , i t  was  a s u p e r i o r method to Per Diem c o s t -  ing for determining p a t i e n t s ' episodic h o s p i t a l costs. i t was  and  e x p e c t e d . l e n g t h of  s e n s i t i v e to s e v e r i t y r e g a r d l e s s  method most s e n s i t i v e to s e v e r i t y was  same l o g i c ,  cost  w i t h s e l e c t e d independent v a r i a b l e s ,  I.S.S. or A.I.S.  of  with  With death as the outcome,  from the Two-Factor ANOVA t e s t s , m u l t i p l e  t h a t c o s t was  change  t o t a l sample, t h i s outcome was  i n j u r y , the s h o r t e r  independent v a r i a b l e s and fied  f o r t h o s e who  d i e d was  i n g f o r t h i s t y p e o f c o s t i n g system. more s e v e r e the  Little  as s e v e r i t y i n c r e a s e s ,  While the number of p a t i e n t s who significantly  (see Graph 5 ) .  s u r v i v e d but, that  pre-  operation.  The  noticed  the  c o n c l u d e d t h a t I.S.S. was  Based on  this  a b e t t e r measure of s e v e r i t y  A.I.S., as both c o s t i n g methodologies were more s e n s i t i v e to  former measure of s e v e r i t y .  the  - 114 -  V.  SUMMARY AND CONCLUSIONS  Episodic  h o s p i t a l costs  have been measured i n t h i s a n a l y s i s  their s e n s i t i v i t y to severity.  t o determine  U s i n g a sample o f motor v e h i c l e  victims  to r e p r e s e n t a l l h o s p i t a l p a t i e n t s ,  i t was shown t h a t  measured by I.S.S., was r e s p o n s i b l e  f o r up t o 46% o f t h e v a r i a t i o n o f  Step-Down c o s t s  under c e r t a i n c o n d i t i o n s .  s e v e r i t y , when  T h i s v a l u e was 8% h i g h e r  t h a n t h e r e l a t i o n s h i p t h a t s e v e r i t y had, when measured by A.I.S. w i t h Step-Down c o s t s . be  applied  tainment.  The r e l a t i o n s h i p i s u s e f u l t o t h e e x t e n t t h a t  i n a n a l y t i c a l studies  on h o s p i t a l c o s t s ,  i t can  such as c o s t  con-  B e f o r e t h i s can be done, t h e r e must be a d d i t i o n a l r e s e a r c h  to  determine i f the c o r r e l a t i o n c a n be improved by changing o r adding variables  i n the r e g r e s s i o n  following  variables:  • sample p o p u l a t i o n  - MVA  analysis.  These changes would f o c u s on t h e  victim  • i n j u r y s e v e r i t y s c a l e - I.S.S. • Step-Down c o s t i n g methodology •  o t h e r independent v a r i a b l e s  Sample P o p u l a t i o n - MVA The  - a v a i l a b i l i t y o f f a m i l y support o r home c a r e - day o f a d m i s s i o n o r d i s c h a r g e .  Victim  two r e a s o n s f o r c h o o s i n g t h i s p a r t i c u l a r group of p a t i e n t s  outlined earlier cost b e n e f i t  i n this report.  analysis  of t r a f f i c  These were the p o t e n t i a l r e t u r n t o accident  p r e v e n t i o n programs, and the  wide range of i n j u r i e s t o d i f f e r e n t body l o c a t i o n s individuals.  I t was assumed t h a t  were  f o r otherwise healthy  these trauma p a t i e n t s  represented  -.115  all  trauma v i c t i m s , r e g a r d l e s s  episodic  Step-Down c o s t  average e p i s o d i c P e r  -  of the  cause o f i n j u r y .  f o r t h e s e MVA  v i c t i m s was  Diem c o s t , s u g g e s t i n g t h a t MVA  s e r v i c e s i n a comparable manner to a l l p a t i e n t s length  of s t a y of MVA  a l l VGH  patients  have 15.2 and  21%  was  10.5  v i c t i m s , however, was  s e p a r a t e d from the s h o r t  days and  an average l e n g t h  b e i n g above 20 d a y s ) . days f o r s h o r t  term u n i t  A n o t h e r group of p a t i e n t s s u r g e r y ) s h o u l d be  The  (e.g.,  q u i t e c l o s e to victims  such as non-trauma p a t i e n t s ,  of the h o s p i t a l s .  ( w i t h 41%  average l e n g t h  for  hospital  elective  sample p o p u l a t i o n i t may  be  severity.  is a  While i t would  to another group of  quite d i f f i c u l t  patients,  to a p p l y the  been geared to the  s c a l e s , such as  surgery severity the  adapted f o r non-trauma v i c t i m s because the m a j o r i t y one  p a r t of the body a t one  time.  i n d i c a t i o n i n the a n a l y s i s o f the r e l a t i o n s h i p between c o s t victims  non-MVA p a t i e n t s .  to i n d i c a t e the  to  individual's injuries.  or an o r t h o p a e d i c  Other simpler  injury  trauma v i c t i m  to measure i n a comparable manner to the  these i l l n e s s e s a f f e c t o n l y  s e v e r i t y f o r MVA  victims  f o r the  p l a s t i c surgery, cancer care,  measurement used i n t h i s r e s e a r c h .  no  MVA  patients.  s e v e r i t y of a c o r o n a r y p a t i e n t  difficult  A.I.S., c o u l d be  The  b e i n g below 5 days  of s t a y  measure s e v e r i t y of the l i f e - t h r e a t e n i n g v a l u e of the  be  o v e r a l l used  term u n i t i n 1975.  of s t a y  s e v e r i t y s c a l e because t h i s s c a l e has  p a t i e n t may  the  used t o r e p e a t t h i s study to determine i f t h e r e  be m e a n i n g f u l to change the  example, the  average  s i g n i f i c a n t l y d i f f e r e n t from  d i f f e r e n t c o r r e l a t i o n v a l u e between c o s t and  For  The  outcome of comparable  of  There i s and research  -  Injury This  Severity  116  -  S c a l e - I.S.S.  s c a l e proved to be more r e s p o n s i v e than A.I.S. i n t h i s r e s e a r c h ,  proved r e l i a b l e i n s e v e r a l o t h e r t e s t s . system has  had  l i m i t e d use,  due  r e s e a r c h which t e s t e d  The  I.S.S. c o d i n g  to i t s r e c e n t development i n the  f i v e y e a r s , i t does seem to have the make v a l i d comparisons.  A l t h o u g h the  and  last  i n t e r n a l consistency necessary  to  l i t e r a t u r e r e v i e w i d e n t i f i e d Semmlow's  I.S.S. and  p o t e n t i a l to survive.''"  In another s t u d y ,  2 Detmer  studied  the  r e l a t i o n s h i p of s e v e r i t y  c e i v i n g poor q u a l i t y of c a r e . of I.S.S. as b e i n g m i n i m a l . that  the  Both s t u d i e s The  Recent s t u d i e s show t h a t  i n order of  in analysis  I.S.S. has  of  the  potential for  a c c e p t e d the  their  re-  internal variation  r e s u l t s of Detmer's r e s e a r c h  I.S.S. c o d i n g system c o u l d  arrange p a t i e n t s  and  suggested  adequately i d e n t i f y s e v e r i t y  and  severity.  trauma i n j u r i e s or  become a s t a n d a r d p a t i e n t  trauma r e g i s t r y systems  c l a s s i f i c a t i o n system f o r  3 severity.  I.S.S. has  become p a r t i c u l a r l y v a l u a b l e when s t u d i e s  made a c r o s s d i f f e r e n t h o s p i t a l s e t t i n g s . ment i n the  c o r r e l a t i o n between the  w i t h another measure of  Semmlow J.L., Detmer D., l  I t i s u n l i k e l y that  c o s t and  s e v e r i t y would be  an  are improve-  achieved  severity.  op.cit.  op.cit.  West J . , Trunkey D., and Lim R., "Systems of Trauma Care - A Study Two C o u n t i e s , " A r c h i v e s of S u r g e r y , Vol.114, A p r i l 1979.  of  -  Other Independent  117  -  Variables  Death as an outcome, and  whether the p a t i e n t had  independent v a r i a b l e s t h a t seem to have had the r e l a t i o n s h i p between c o s t and entered  i n t o the e q u a t i o n ,  v a r i a t i o n of c o s t . ables  The  significant  severity.  influence  o b j e c t i v e of i n t r o d u c i n g o t h e r  As  an  example, l e n g t h  a c r i t i c a l component o f c o s t a n a l y s i s .  influence length  of s t a y c o u l d be  considered  be  internal  independent  i s to r e d u c e the n o n - c l i n i c a l o r n o n - p a t i e n t c a r e  as v a l u a b l e  vari-  influences  of s t a y has  Therefore,  two  on  Other v a r i a b l e s c o u l d  to t r y to e l i m i n a t e some of the  hospital episodic costs. t o be  an o p e r a t i o n , were  on  been shown  f a c t o r s which independent  v a r i a b l e s i n the r e g r e s s i o n of h o s p i t a l e p i s o d i c c o s t s and  severity.  Representative  f a c t o r s t h a t i n f l u e n c e l e n g t h of s t a y i n c l u d e p o t e n t i a l  for discharge,  which may  f a m i l y s u p p o r t , and  be measured i n a v a i l a b i l i t y  d a t e of a d m i s s i o n , s u g g e s t i n g  of home c a r e  t h a t weekday admissions  d i f f e r from weekend a d m i s s i o n s f o r e p i s o d i c c o s t s when o t h e r constant.  This  l a t t e r f a c t o r , date of a d m i s s i o n , c o u l d be  patients' medical records,  but  research  charge would be based on i n t e r v i e w s workers  (such  as n u r s i n g  staff  and  therefore  i n v o l v e a l a r g e number of  Step-Down  Costing  Improving the v a l i d i t y  of the  or  f a c t o r s are  obtained  to determine p o t e n t i a l f o r d i s -  w i t h the p a t i e n t and  allied  s o c i a l services personnel),  health and  component c o s t s  severity.  would  assumptions.  t h a t were t o t a l l e d t o make  Step-Down e p i s o d i c c o s t s i s the most n e c e s s a r y improvement t o the t i o n between c o s t and  from  correla-  D e t e r m i n i n g u s a b l e Step-Down e p i s o d i c  c o s t s of a s i n g l e p a t i e n t s t a y was  an arduous t a s k .  S e v e r a l of  the  -  118  -  m e t h o d o l o g i e s used to develop u n i t c o s t s had and  their validity  needed by  increased.  the p a t i e n t was  the p o t e n t i a l to be  W h i l e the number of u n i t s of  relatively  c o s t to each s e r v i c e u n i t .  Identifying  the  i n p a t i e n t beds by  however, i d e n t i f y  f o r each day  of h i s / h e r  sophisticated a l e n t , but  c o s t s , as  s p e c i a l t y , as was  this is  r e q u i r e m e n t s by n u r s i n g  unit; i t did  the i n d i v i d u a l a t t e n t i o n needed by  each p a t i e n t  stay.  T h i s i d e n t i f i c a t i o n p r o c e s s i s more  not  as a c c u r a t e  needs are  needs of the p a t i e n t s  equiv-  as a p a t i e n t c l a s s i f i c a t i o n system.  improved i d e n t i f i c a t i o n system would have h e l p e d t o i d e n t i f y  to the p a t i e n t ' s  of  done i n t h i s t h e s i s ,  than assuming t h a t a l l p a t i e n t s ' n u r s i n g  i t is  difficulties  c o s t component of most p a t i e n t s ' s t a y i n the h o s p i t a l .  a l l o w e d f o r v a r i a t i o n of s t a f f i n g not,  the  division  The most i m p o r t a n t  t h e s e u n i t c o s t s t h a t needs improvement i s n u r s i n g the s i n g l e h i g h e s t  service  easy to c a l c u l a t e f o r each  o f the h o s p i t a l by u s i n g p a t i e n t s ' m e d i c a l r e c o r d s , arose i n a s s i g n i n g  refined  the  An  nursing  on many l e v e l s , some of which c o u l d have been r e l a t e d  i n j u r y , and  thus to the  severity scale, while  would have been r e l a t e d t o d i f f e r e n t p e r s o n a l  others  c h a r a c t e r i s t i c s such  as  4 ability  t o communicate, age,  G e r s o n ^ went one  step  and  p s y c h o l o g i c a l or s o c i a l needs.  f u r t h e r than simply  as a management of n u r s i n g  time by  patient  classification  p r e d i c t i n g d a i l y nursing  the p a t i e n t ' s l e n g t h of s t a y based on of h i s r e s e a r c h ,  using  the a d m i t t i n g  Lowell  c a r e needs over  diagnosis.  p r o f i l e s of c a r e were d e v e l o p e d f o r j u s t a few  At  " P a t i e n t P r o f i l e s of H o s p i t a l Care," 1973.  time  ICDA codes  Y o u e l l L., " P a t i e n t C l a s s i f i c a t i o n Program," Dimension i n H e a l t h November 1979, p.17. 'Gersen L., Vol.50(9),  the  Service,  Canadian H o s p i t a l ,  - 119 -  i n t h e 800 s e r i e s , s p e c i f i c a l l y , Since  those d e a l i n g with  accidental  injuries.  t h e A.I.S. code had a l s o been c o r r e l a t e d t o the ICDA code,  there  i s p o t e n t i a l i n f u t u r e s t u d i e s t o l i n k a s e v e r i t y s c a l e and a p a t i e n t p r o f i l e s c a l e , which would be o f g r e a t the n u r s i n g  If  c o s t s o f the MVA v i c t i m by s e v e r i t y l e v e l .  the v a l i d i t y  o f c o s t s o f component s e r v i c e s used by each p a t i e n t  c o u l d be i n c r e a s e d , of a n a l y z i n g  e s p e c i a l l y f o r n u r s i n g and ward c o s t s , t h e p o t e n t i a l  t h e r e l a t i o n s h i p o f s e v e r i t y and treatment c o s t s as i d e n t i -  f i e d by C l o v e r d a l e following  assistance i n d i f f e r e n t i a t i n g  et a l ^ would be r e a l i z e d .  They i d e n t i f i e d t h e  t h r e e components o f h o s p i t a l c o s t s :  e Overhead c o s t s — t h o s e c o s t s w h i c h v a r y w i t h r a t h e r than i t s throughput; • H o t e l c o s t s — t h o s e c o s t s which v a r y w i t h o c c u p i e d i n the h o s p i t a l ; 0 Treatment c o s t s — t h o s e patients treated.  the s i z e o f the h o s p i t a l  the number o f beds which a r e  c o s t s which v a r y w i t h  the type and number o f  I f a more r e f i n e d treatment c o s t c o u l d be i d e n t i f i e d , a much c l o s e r r e l a t i o n s h i p w i t h patient could  severity.  t h e r e s u l t would b  Overhead and h o t e l c o s t s p e r  then be more e a s i l y p r e d i c t e d , based on t h e e s t i m a t e d  l e n g t h o f s t a y o f t h e p a t i e n t as w e l l as s e v e r i t y combined w i t h  diagnose  C o v e r d a l e J . , Gibbs R., and Nurse K., "A H o s p i t a l Cost I'odel f o r P o l i c y A n a l y s i s , " The J o u r n a l o f t h e O p e r a t i o n a l Research S o c i e t y , V o l . 3 1 , Sept. 1980.  - 120  Utility The  of R e l a t i o n s h i p Between E p i s o d i c Cost and  utility  costs  -  can be  of the r e l a t i o n s h i p between s e v e r i t y and defined  r e p o r t i n g systems.  by The  its ability greatest  can  be  s i n g l e f a c t o r i n j u s t i f y i n g and  comparable to or b e t t e r  repeated f o r other  become a s t a n d a r d  Assuming t h a t a  regression  than t h a t produced i n t h i s  p a t i e n t g r o u p s , s e v e r i t y has  ex-  thesis  the p o t e n t i a l t o  component of p a t i e n t c l a s s i f i c a t i o n systems which  would d e f i n e p a t i e n t  I n the l a s t  hospital episodic  to i n f l u e n c e h o s p i t a l f i n a n c i a l  p l a i n i n g h o s p i t a l c o s t s i s p a t i e n t mix. co-efficient  Severity  mix.  several years,  d i a g n o s t i c - r e l a t e d groups (DRG's) or  major codes have been used r e p e a t e d l y wide range of p l a n n i n g i n t r o d u c t i o n of new  categories  for a  i s s u e s , i n c l u d i n g models f o r d e t e r m i n i n g bed  medical/surgical  physician recruitment.  as p a t i e n t c a r e  ICD  Rousseau and  programs, reimbursement, GibbJ  were too heterogeneous f o r t h e i r needs.  To  found t h a t ICD  needs,  and  chapter headings  improve t h e i r model f o r simu-  l a t i n g h e a l t h c a r e system b e h a v i o r , they c o n c l u d e d t h a t a d i f f e r e n t c a t e g o r i z a t i o n of p a t i e n t s was more homogeneous w i t h r e s p e c t of a d m i s s i o n r a t e ) .  Studies  r e d u c e i n t e r n a l v a r i a t i o n , as 18  f o r the major ICD  codes.  needed, such t h a t each c a t e g o r y would to i n t e r n a l e l a s t i c i t i e s  i n v o l v i n g DRG  have g r e a t e r  t h e s e groups t o t a l 383 But  (e.g.,  be  elasticity  opportunities  to  compared w i t h j u s t  concerns have d e v e l o p e d i n u s i n g DRG  for  t h i s purpose, r e s u l t i n g i n a r e - o r g a n i z a t i o n o f p a t i e n t d i a g n o s e s i n t o 562  groups.  The  o r i g i n a l 383  groups were developed f o r  utilization  Rousseau J . , and Gibbs R.J., "A Model to A s s i s t P l a n n i n g the P r o v i s i o n of H o s p i t a l S e r v i c e s , " The J o u r n a l of the O p e r a t i o n a l Research S o c i e t y , V o l . 3 2 , No.6, June 1981.  - 121 -  r e v i e w purposes and d i d n o t s u i t reimbursement s t u d i e s . " groups have been d e f i n e d  so as t o be c l i n i c a l l y  W h i l e t h i s number may appear t o be u n w i e l d l y f a c t o r has been b u i l t  The new 562  s u i t e d t o reimbursement.  f o r general  u s e , an age  i n t o t h e c h a r a c t e r i z a t i o n o f these new groups, t o  account f o r the v a r i a t i o n i n r e s o u r c e u t i l i z a t i o n o f t h e e l d e r l y length  o f s t a y v a r i a t i o n by a g e ) .  Most g e n e r a l  (i.e.,  h o s p i t a l s w i l l use o n l y  40-60 of t h e s e new DRG's, as they w i l l n o t have adequate samples i n t h e o t h e r groups t o ensure v a l i d reimbursements f o r c a r e g i v e n  to their  patients.  The i m p l i c a t i o n o f d a t a a n a l y s i s of t h i s t h e s i s I.S.S. can be r e s p o n s i b l e  (that a s e v e r i t y s c a l e -  f o r 46% o f t h e v a r i a t i o n i n e p i s o d i c  under c e r t a i n c i r c u m s t a n c e s ) ,  s u g g e s t s t h a t a new p a t i e n t  system needs to be d e v e l o p e d which i n c l u d e s  costs  classification  a s e v e r i t y component.  This  new p a t i e n t  c l a s s i f i c a t i o n system would be p a r t i c u l a r l y u s e f u l f o r r e -  imbursement  a n a l y s i s and would have a p p l i c a t i o n i n o t h e r l o n g  planning not  exercises.  W h i l e t h e I.S.S. s c o r e  a p p l i c a b l e f o r non-trauma  s c o r e which measures included  range  may be too c o m p l i c a t e d and  patients, a modification  of t h e A.I.S.  l i f e - t h r e a t e n i n g d i a g n o s e s , c o u l d be as e a s i l y  i n a p a t i e n t c l a s s i f i c a t i o n system as age was i n c l u d e d  new 562 DRG's.  Severity  combined w i t h d i a g n o s i s  f o r an e x c e l l e n t methodology f o r a c c u r a t e l y episodic hospital  provides the v a r i a b l e s  predicting variations i n  costs.  P e r s o n a l Communication, T r e n t o n , New J e r s e y .  New J e r s e y  i n the  S t a t e Cr-partment o f H e a l t h ,  - 122  -  APPENDIX A  Implications The  of Data A n a l y s i s i n R e f e r e n c e t o I.C.B.C.  sample p o p u l a t i o n was  f o r reasons l i s t e d  drawn from motor v e h i c l e a c c i d e n t  i n the main t e x t of t h i s r e p o r t , and  I.C.B.C. i n i t s l o n g range p l a n n i n g . be  i m p o r t a n t t o I.C.B.C. would be  Per Diem c o s t s of MVA  v i c t i m s and  Two  to  victims assist  major f i n d i n g s t h a t  could  the comparison of Step-Down to the p e r c e n t a g e of v i c t i m s i n each  c e l l o f the s e v e r i t y s c a l e .  Comparing E p i s o d i c C o s t s As  a s i n g l e group of i n p a t i e n t s , MVA  cost, using  v i c t i m s had  an average e p i s o d i c  step-down c o s t i n g methodology, of $1,936.10.  s l i g h t l y below the average e p i s o d i c c o s t , u s i n g methodology, of $1,984.15. significantly  c o u l d be  While i n d i v i d u a l p a t i e n t ' s costs v a r i e d  from one methodology t o the o t h e r ,  of v a l u e  just  per diem c o s t i n g  t h e r e was  cant d i f f e r e n c e when a l l p a t i e n t s ' c o s t s were t o t a l l e d data  T h i s was  no  signifi-  together.  This  i f and when, i n the f u t u r e , h o s p i t a l r e i m b u r s e -  ments a r e based on c a s e mix,  or a c o m b i n a t i o n of d i a g n o s e s and  If  the system were to change, t h e r e  be  a significant  i s no  i n d i c a t i o n t h a t t h e r e would  i n c r e a s e or d e c r e a s e i n the  t o t a l h o s p i t a l cost  t r e a t a l l motor a c c i d e n t v i c t i m s , compared to the p r e s e n t reimbursement u s i n g a s e t per  diem r a t e .  severity.  to  method of  122A  LITERATURE CITED  - 123  P a t i e n t D i s t r i b u t i o n by The  Severity  largest concentration  of MVA  range, w i t h an I.S.S. v a l u e low  -  i n p a t i e n t s was  of l e s s  than 10.  i n the low s e v e r i t y  I n d i v i d u a l patients with  s e v e r i t y were shown to have lower h o s p i t a l e p i s o d i c c o s t s  those p a t i e n t s with higher s e v e r i t y v a l u e s . bined  c o s t s of low  But  than  as a group, the com-  s e v e r i t y p a t i e n t s were l a r g e r t h a n t h e combined  costs  of a l l o t h e r p a t i e n t s .  I f f u t u r e p r e v e n t i v e programs a r e to be f o c u s s e d B r i t i s h Columbia highways, t h e r e would not health care c o s t s .  h i g h h o s p i t a l c o s t f o r acute  cent and  rehabilitation  focussed  on r e d u c i n g  care.)  care.  with  (Additional costs  i n c u r r e d f o r extended,  convales-  I f f u t u r e p r e v e n t i v e programs a r e to  s e v e r i t y of a l l i n j u r i e s  i n h o s p i t a l c o s t c o u l d be r e a l i z e d .  i n equal p r o p o r t i o n , F o r example, i f a  an o v e r a l l r e d u c t i o n of 10%  (see f o l l o w i n g g r a p h ) ;  but  t h e r e would be  10%  to the low s e v e r i t y  groups, e s p e c i a l l y A . I . S . - l and A.I.S.-2, which have lower h o s p i t a l episodic  costs.  there  of the h o s p i t a l s ' p a t i e n t s a shift  be  then  s h i f t downward were r e a l i z e d f o r each of the f i v e c e l l s of A.I.S., would not be  on  l i k e l y be a r e d u c t i o n i n  s u r v i v e w i l l have a h i g h s e v e r i t y r a t i n g ,  to the h e a l t h c a r e system would a l s o be  reductions  deaths  T h i s statement i s made on t h e assumption t h a t a l a r g e  p e r c e n t a g e o f t h o s e who a correspondingly  on r e d u c i n g  - 124 -  906 H o s p i t a l i z e d MVA  i n 1975 i n Vancouver G e n e r a l H o s p i t a l  A.I.S. L e v e l  Number o f P a t i e n t s  10% R e d u c t i o n  New  Total  5  29  ( 29- 3)= 26  4  97  ( 97-10)= 87  3  610  (610-61)=549  549 + 10=559  2  143  (143-14)=129  129 + 61=190  1  27  ( 27- 3)= 24  24 + 14= 38  26 + 10% o f Deaths 87 +  3= 90  - 125 LITERATURE CITED  American H o s p i t a l A s s o c i a t i o n , Cost F i n d i n g s f o r H o s p i t a l s , Chicago, 1957. Baker S. e t a l , "The I n j u r y S e v e r i t y Score - A Method f o r D e s c r i b i n g P a t i e n t s w i t h M u l t i p l e I n j u r i e s and E v a l u a t i n g Emergency Care," J o u r n a l o f Trauma, March 1974. Baker S.P., O ' N e i l l B., Haddon W., and Long W.B., "The I n j u r y S e v e r i t y Scale: Development and P o t e n t i a l U s e f u l n e s s " P r o c e e d i n g s o f the 18th C o n f e r e n c e of the American A s s o c i a t i o n f o r A u t o m o b i l e M e d i c i n e . Lake B l u f f , 111. AAAM 1974. B e r r y R.E., "Product 7-67, March 1970.  Heterogenity  Bowman R., "DRG's H e l p Trace January 1980.  and H o s p i t a l Cost A n a l y s i s , " I n q u i r y ,  Revenue S o u r c e s , " Modern H e a l t h  Care,  Boyd D.R. e t a l , "Trauma R e g i s t r y New Computer Method f o r M u l t i f a c t o r i a l E v a l u a t i o n of Major H e a l t h Problems," JAMA Vol.223,1973. Chipman M.L., " H o s p i t a l i z a t i o n a f t e r MVA i n Nova S c o t i a , " Canadian J o u r n a l of P u b l i c H e a l t h , V o l . 6 4 , March 1973. Committee on M e d i c a l A s p e c t s of Automotive S a f e t y , " R a t i n g the S e v e r i t y of T i s s u e Damage I The A b b r e v i a t e d I n j u r y S c a l e , " JAMA, J a n 11 1971, Vol.215 No. 2. Committee on M e d i c a l A s p e c t s o f Automotive S a f e t y , " R a t i n g the S e v e r i t y of T i s s u e Damage I I The Comprehensive I n j u r y S c a l e , " May 1 1972, Vol.220 No. 5. C o v e r d a l e J . , Gibbs R., and Nurse K., "A H o s p i t a l Cost Model f o r P o l i c y A n a l y s i s , " The J o u r n a l of the O p e r a t i o n a l Research S o c i e t y , V o l . 3 1 , Sept.1980. Cowley e t a l , "A P r o g n o s t i c December 1974. D e c o s t e r D.T., S c h a f e r E.L., T o r o n t o , 1979, pg.693.  Index f o r Severe Trauma," J o u r n a l of Trauma,  Management A c c o u n t i n g ,  Wiley  and Sons,  Detmer D., e t a l , " Q u a l i t y of Care f o r Major Trauma," J o u r n a l o f Trauma, V o l . 1 6 , No.7, 1976, pg.522. D i t t m a n D.A., and Smith K.R., " C o n s i d e r a t i o n o f B e n e f i t s and C o s t s : A C o n c e p t u a l Framework f o r t h e H e a l t h P l a n n e r , " H e a l t h Care Management Review, F a l l 1979. E l n i c k i R.A., " H o s p i t a l P r o d u c t i v i t y , S e r v i c e I n t e n s i t y , and C o s t , " H e a l t h S e r v i c e s R e s e a r c h, W i n t e r 1974. Evans R.G., and R o b i n s o n G.C., " E v a l u a t i o n o f t h e Economic I m p l i c a t i o n s of a Day Care Surgery U n i t , " Report t o C h i l d r e n ' s H o s p i t a l , Vancouver, B.C., 1973.  - 126 -  F a r g a n B.M., "1975 S o c i e t a l C o s t s o f Motor V e h i c l e A c c i d e n t s , " U.S. Department o f T r a n s p o r t a t i o n , N a t i o n a l Highway T r a f f i c S a f e t y A d m i n i s t r a t i o n , December 1976, page 30. F e l d s t e i n M., " H o s p i t a l Cost V a r i a t i o n and Case Mix D i f f e r e n c e s , " M e d i c a l Care, 3, 95-103, A p r i l - J u n e 1965. F r a n k W.G., "A M a n a g e r i a l A c c o u n t i n g A n a l y s i s o f H o s p i t a l H e a l t h S e r v i c e s Research,. S p r i n g 1976.  Costs,"  Gerson L., " P a t i e n t P r o f i l e s o f H o p s i t a l Care," Canadian H o s p i t a l , V o l . 5 0 ( 9 ) , 1973. G r o s s e R.N., " C o s t - B e n e f i t A n a l y s i s of H e a l t h S e r v i c e s , " American Academy o f P o l i t i c a l and S o c i a l S c i e n c e s , P h i l . Annuls 399, 1972. Haddon W., "Reducing Damage of Motor V e h i c l e Use," Technology Review, J u l y / A u g u s t , 1975. Haddon W., Suchman E.A., and K l e i n D., A c c i d e n t Approaches, New York, Harper & Row, 1964.  Research - Methods and  Haddon W., "The T r a n s i t i o n t o Approaches E t i o l o g i c a l l y r a t h e r than D e s c r i p t i v e l y Based, w i t h r e s p e c t t o E p i d e m i o l o g y P r e v e n t i o n and A m e l i o r a t i o n o f Trauma," American J o u r n a l o f P u b l i c H e a l t h , V o l . 5 8 , August 1968. H o l d e r W.W., " H o s p i t a l B e d g e t i n g : S t a t e o f the A r t , " H o s p i t a l s and H e a l t h S e r v i c e s A d m i n i s t r a t i o n , V o l . 2 3 , No.2, S p r i n g 1978. Klarman H.E., " A p p l i c a t i o n s o f Cost B e n e f i t A n a l y s i s t o the H e a l t h S e r v i c e s and t h e S p e c i a l Case o f T e c h n o l o g i c I n n o v a t i o n , " I n t ernat i o n a l J o u r n a l o f H e a l t h S e r v i c e s , V o l . 4 , No.2, Nov 2, 1974. K r i s c h e r J.P., "Indexes o f S e v e r i t y : U n d e r l y i n g S e r v i c e s R e s e a r c h, Summer 1976.  Concepts,"  Health  L a l o n d e M., "A New P e r s p e c t i v e o f t h e H e a l t h o f Canadians: A Working Document," Ottawa, A p r i l 1974. Lave J.R., and Lave L.B., " H o s p i t a l Cost F u n c t i o n s , " American Economic Review, 60:379, June 1970. Lave J.R., and Lave L.B., "The Extent o f R o l e D i f f e r e n t i a t i o n Among H o s p i t a l s , " H e a l t h S e r v i c e s R e s e a r c h , S p r i n g 1971. Lay C , "What i s D i s e a s e C o s t i n g ? " U n p u b l i s h e d R e p o r t , H e a l t h i s t r a t i o n , F a c u l t y of A d m i n i s t r a t i o n , U n i v e r s i t y of Ottawa.  Admin-  L y n c h T., " R e p o r t t o the I n f o r m a t i o n Systems S t e e r i n g Committee of O n t a r i o M i n i s t r y o f H e a l t h , " O n t a r i o H o s p i t a l A s s o c i a t i o n , October 20, 1978. Macdonald L.K., and Reuter F., "A P a t i e n t S p e c i f i c Approach to H o s p i t a l Cost A c c o u n t i n g , " H e a l t h S e r v i c e s R e s e a r c h, Summer 1973.  - 127 -  Magraw R.W., M.D., "How Trends i n M e d i c a l E d u c a t i o n M e d i c i n e and H o s p i t a l , " H o s p i t a l s , O c t o b e r 1, 1963.  are Affecting  M a r t i n D.L., H e a l t h Program E v a l u a t i o n - A Primer Report t o the F e d e r a l - P r o v i n c i a l Sub-Committee on Q u a l i t y o f Care and Research and F e d e r a l - P r o v i n c i a l A d v i s o r y Committee on H e a l t h I n s u r a n c e , 1977 V o l . 1 M a r t i n D.L., H e a l t h Program E v a l u a t i o n - A P r i m e r R e p o r t t o the F e d e r a l - P r o v i n c i a l A d v i s o r y Committee on H e a l t h I n s u r a n c e , 1977 V o l . 1 1 Moylan M.D. et a l , " E v a l u a t i o n o f t h e Q u a l i t y o f H o s p i t a l Care f o r M a j o r Trauma," J o u r n a l o f Trauma, V o l . 1 6 #7, J u l y 1976. Murray J.E., " E t i o l o g y of MVA w i t h S p e c i a l R e f e r e n c e to the Mechanism of I n j u r y , " N.E. J o u r n a l o f M e d i c i n e NE 492, June 20, 1968. Musgrave R.A., "Cost B e n e f i t A n a l y s i s and t h e Theory of P u b l i c J o u r n a l o f Economic L i t e r a t u r e , V o l . 7 , No.3, 1969.  Finance,"  Mushkin S.J. and C o l l i n g s F.d'A., "Economic Costs o f D i s e a s e and I n j u r y , " P u b l i c H e a l t h R e p o r t s , V o l . 7 4 , No.9, Sept. 1959. Noble J . e t a l , Emergency M e d i c a l P e r s p e c t i v e s , New York, B e h a v i o u r a l  Services: Behavioural P u b l i c a t i o n s , 1973.  Planning  Ogawa M. and Sugimoto T., " R a t i n g S e v e r i t y o f the I n j u r e d by Ambulance A t t e n d a n t ; F i e l d Research o f Trauma Index," J o u r n a l o f Trauma, Nov. 1974. R i c e D.P., " E s t i m a t i n g the C o s t o f I l l n e s s , " American J o u r n a l of P u b l i c H e a l t h , V o l . 5 7 , No.3, March 1967. Rousseau J . , and Gibbs R.J., "A Model t o A s s i s t P l a n n i n g t h e P r o v i s i o n of H o s p i t a l S e r v i c e s , " The J o u r n a l of t h e O p e r a t i o n a l Research S o c i e t y , Vol.32, No.6, June 1981. Schwenger C , " A l c o h o l and Highway S a f e t y , " Report the S e c r e t a r y o f T r a n s p o r t a t i o n , 1967.  t o Congress from  Semmlow J . L . and Cone R., " U t i l i t y o f t h e I n j u r y S e v e r i t y A C o n f i r m a t i o n , " H e a l t h S e r v i c e s Research, S p r i n g 1976.  Score:  S t a n f o r d Center f o r H e a l t h Care R e s e a r c h , "Comparison o f H o s p i t a l s w i t h Regard t o Outcomes o f S u r g e r y , " H e a l t h S e r v i c e s R e s e a r c h , Summer 1976. S t o d d a r t G.L., On D e t e r m i n i n g t h e E f f i c i e n c y o f H e a l t h Programs, U n p u b l i s h e d a r t i c l e , Department o f C l i n i c a l Epidemology and B i o s t a t i s t i c s and Department of Economics, McMaster U n i v e r s i t y , November 1980. Thompson J.D., "On Reasonable Cost o f H o s p i t a l S e r v i c e s , " M i l l b a n k Memorial Fund Q u a r t e r l y , 46(1):33 J a n u a r y 1968 P a r t 2.  - 128 -  Thompson J.D., A v e r i l l R.F. , and F e t t e r R.B., " P l a n n i n g Budgeting and C o n t r o l l i n g - O n e Look a t t h e F u t u r e : Case M i x Cost A c c o u n t i n g , " H e a l t h S e r v i c e s R e s e a r c h , Summer 1979. T o r r a n c e G.W., Thomas W.H., and S a c k e t t D.L., "A U t i l i t y M a x i m i z a t i o n Model f o r E v a l u a t i o n o f H e a l t h Care Programs," H e a l t h S e r v i c e s Research, Summer 1972. W e i n s t e i n M.C., and S t a s o n W.B., " A l l o c a t i o n o f Resources t o Manage H y p e r t e n s i o n , " The New England J o u r n a l o f M e d i c i n e , March 31, 1977. W e i n s t e i n M.C., and Stason W.B., "Foundations o f C o s t - E f f e c t i v e n e s s A n a l y s i s f o r H e a l t h and M e d i c a l P r a c t i c e s , " The New England J o u r n a l o f M e d i c i n e , March 31, 1977 West J.,'Trunkey D., and L i m R., "Systems o f Trauma Care - A Study o f Two C o u n t i e s , " A r c h i v e s o f Surgery, Vol.114, A p r i l 1979. W.H.O., " A c c i d e n t s i n a S o c i a l C o n t e x t , " C h r o n i c l e 27, 1973. Y o u e l l L., "Patient C l a s s i f i c a t i o n November 1979, p.17.  Program," Dimensions i n H e a l t h S e r v i c e ,  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0095314/manifest

Comment

Related Items